Complex Case Management Application and Referral Form

The purpose of this form is to determine eligibility for the complex case management program. Complex Case Management (CCM) is an enhanced service that assists people in coordinating all of their immediate healthcare and community resource needs. The CCM program is available to individuals who are receiving services through OCHN's network, have a MANAGED MEDICAID plan as their primary insurance, have a medical diagnosis, and meet any of the service criteria provided in this form.

Applicant Information

Please indicate if this is an application for yourself or a referral for someone else:*

(First and Last name)

Does the applicant/person being referred have a guardian?

Referral Information

(First and Last name)

Select or enter value
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Please provide a brief description of the reason you are referring this individual.

Does the referred individual have a guardian?*
Was the referred individual informed of this referral?*
Did the referred individual agree to the referral?

Health Plan and Provider Information

Please note that you must have a managed Medicaid plan as your primary insurance to be eligible for complex case management services. If you have Medicare as your primary insurance, you are not eligible for these services but can request information by emailing complexcasemanagement@oaklandchn.org.

Health Plan and Provider Information

Provide the following health plan information for the individual you are referring. Please note that only individuals with a managed Medicaid plan as their primary insurance are eligible for complex case management services. Individuals with Medicare are not eligible, but can request information by emailing complexcasemanagement@oaklandchn.org.

Medicaid health plan:

Current provider agency:

(If "other" was selected above)

(MD, PA, NP)

(This includes both medical and behavioral conditions)

Service Criteria

The following service criteria will be considered when determining eligibility. Please select all that apply to you.

Service Criteria

The following service criteria will be considered when determining eligibility. Please select all that apply to the individual you are referring.

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