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About Us
ECM Services
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Justice Involved
Referral Partners
Consent Form
More

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Enhanced Care Management

I agree to participate in the Enhanced Care Management (ECM) program and share data with my care team.

I understand: *The purpose of ECM is to help me better manage my health.My participation in this program will give me a care team to help me better understand and manage my health.Participation in ECM will not affect my other medical benefits.ECM does not require me to change my doctor(s).ECM services end if I no longer meet ECM eligibility requirements, I no longer receive ECM services, or if the care team says I no longer need ECM services.ECM is a voluntary program, and I may withdraw from the program at any time.

Member Enrollment Date

ECM Provider

Print Member Name

Member CIN #

Date of Birth (MM/DD/YYYY)

Send Form To (Email)

Member Signature

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Parent or Legal Guardian (if applicable)ParentLegal Guardian

Guardian Name

Parent / Legal Guardian Signature (if applicable)

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Guardian Relationship (if applicable)

ECM Care Team Member Name

Care Team Member Signature

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Phone:

(909) 263-8255

Address:

2040 N. Garey Ave Pomona, CA 91767

Email:

contact@lglinkisinc.org

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