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Integrated Care Management Program (ICMP) Referral Form
Required Fields
 Member First Name:
 Member Last Name:
 Region:
Address:
 Town:
 Zip Code:
Phone #:
Best Time to Contact:
Date of Birth:
Gender:
Explain:
MassHealth Member ID#: (if ID# not available, please provide Social Security #):
Legal guardian/custody: Cultural background:

Language:

Where is Member now? (e.g., home, my office, other?)

Referred by:
-OR-
First Name:
 Last Name:
 Title:
Agency/Dept.:
Phone:

If known, list agency/agencies involved in your or the Member's care below:
Agency/Provider Name Contact Person Name Regional Office (or N/A) Phone Number
Primary Care Clinician
Outpatient Therapist
Specialist
Psychiatrist
DMH (Department of Mental Health)
DCF (Department of Children and Families)
DYS (Department of Youth Services)
DDS (Department of Developmental Services)

Reason for Referral:

Provide brief explanation of referral reason including potential goals for Care Management:

PCC PRACTICES ONLY: Complete below if you operate your own care management program

Select one or more REFERRAL REASON, as applicable
If you have questions, please call the ICMP at 1-800-495-0086, Ext. 706870.