CHILD/YOUTH ECM REFERRAL FORM

1. MEMBER INFORMATION

Date of Referral

Member Full Name:

Date of Birth (MM/DD/YYYY)

Medi-Cal CIN / MCP ID:

Managed Care Plan*:

Member Preferred Language: *EnglishSpanishOther

Street Address

City

State/Province

ZIP / Postal Code

Country

Parent/Guardian Name:

Best Contact Phone

Type of Referral:RoutineExpedited

2. REFERRAL SOURCE INFORMATION (Your Details)

Referring Organization Name

Referring Individual Name

Referring Individual Title

Phone Number

Email Address

Relationship to Member:Medical ProviderSocial Services ProviderOther

Presumptive Authorization Providers Only

Has the Member already started ECM services?Yes → ECM Benefit Start Date:NoOther

LG LINKS INC. – CHILD/YOUTH ECM REFERRAL FORM