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

Cultural background:


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

The Referral is for (please check the appropriate box below):

Is the Member aware of the referral?
If the answer is no, please notify the Member that a referral is being made.

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: Please check the appropriate box below.

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

If you have questions, please call to the ICMP 800-495-0086, Ext. 706870.