Mental Health and Substance Use Care Management Program Referral Form

Use this form to refer a member whom you assess as CM eligible. Silversummit will assess the member’s eligibility and respond with next steps or request more information within one week.

Asterisk (*) identifies required information field.

Referal Souce Information

Date of Request:

Referring Individual Name: *

Referring Organization Name: *

Referrer Phone Number: *

Has the Member expressed interest in opting into Case Management? Yes, I have already discussed the program with the Member. No

Comments relating to above:

Member Information

Member Name: *

Member ID number: *

Member DOB: *

Members address:

Parent/Guardian Name (if applicable):

Member primary phone number: *

Members preferred language:

Member email address:

Is Member currently Pregnant? Yes No

If yes, Estimated Date of Confinement (EDC):

REASON FOR REFERRAL (Check all that apply): * Individual experiencing Behavioral Health (BH/MH) Individual reports Substance/Alcohol Use Disorder

Concern:

Additional Comments: