PCP/Provider Request for Care Manager Name or Assignment Referral Form

PCP/Provider Request for Care Manager Name or Assignment Referral Form

This form is for Primary Care Physican Offices or Behavioral Health Providers to request a member receive a Care Management assignment or request the name of a member's assigned CM. If your request is not related to CC/CM, but related to issues as a Trillium Provider, please contact Trillium Health Resources Provider Support Services at 855-250-1539

Is this request for CM/CC Assignment or Name?*

If you have an urgent or emergent member situation where you feel a care management assignment needs to be expedited, please contact the Member & Recipient Services line at 1-877-685-2415

Select or enter value

Have you checked NC Tracks for TCM Assignment?*

Select or enter value

Member First Name*

Member Last Name*

DOB*

Phone Number for Member/LRP*

Phone

Medicaid ID# or TBS#*

If listing Medicaid ID #, please do not put any dashes

Insurance*

Select or enter value

Member's County*

Date of Request/Referral*

Name of Person Submitting Request*

Title of Person Making Request/Referral

Name of Organization Making the Request/Referral*

Phone Number*

Phone

Email*

Organization Type*

Select or enter value

Date of Last Contact with Member *

Assistance Needed*

Select or enter value

Brief Description of Request*

Member Assistance with Social Determinants of Health (SDOH)

General Request for Care Management

Care Management for complex case issue

Emergency Department or Inpatient Disposition Program

1915i Related

Additional Information Regarding Referral*

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