ECM Prequalification Application

This form is not functional

Member Last NameReferral Date

Member Last NameMember Last NameReferral TypeRoutineExpedited

Member Last Name

Member First Name

Date of Birth

AgeAge

Preferred Language

Medi-Cal CIN

CenCal Member ID

Primary Phone

Member Email

Residential address

No fixed current addressNo fixed current addressNo fixed current address

Frequently visited location

Member Last NameCity

Member Last NameState

Member Last NameZIP

Member Last NamePrimary Care Provider / Clinic

Member Last NameMember Last NameBest Contact MethodPhoneEmailText

Member Last NameBest Time to Call

Member Last NameCaregiver name

Member Last NameRelationship

Member Last NameCaregiver phone

Member Last NameCaregiver email

Member Last NameBest Time to Call

Member Last NameMember Last NameDiscriptionYesNoUnknown

Member Last NameMember Last NameAdults experiencing homelessnessAdults experiencing homelessness

Member Last NameMember Last NameAdults at risk for avoidable hospital or emergency department utilizationAdults at risk for avoidable hospital or emergency department utilization

Member Last NameMember Last NameAdults with serious mental health and/or substance use disorder (SUD) needsAdults with serious mental health and/or substance use disorder (SUD) needs

Member Last NameMember Last NameAdults transitioning from incarceration / correctional facility within the past 12 monthsAdults transitioning from incarceration / correctional facility within the past 12 months

Member Last NameMember Last NameAdults living in the community who are at risk for long-term care (LTC) institutionalizationAdults living in the community who are at risk for long-term care (LTC) institutionalization

Member Last NameMember Last NameAdult nursing facility residents transitioning to the communityAdult nursing facility residents transitioning to the community

Member Last NameMember Last NameBirth Equity - pregnant or postpartum individuals at risk for adverse perinatal outcomes

Enter the criteria or supporting information that applies.

Children/youth experiencing homelessness, including families with children/youth

Children/youth at risk for avoidable hospital or emergency department utilization

Children/youth with serious mental health and/or substance use disorder (SUD) needs

Children/youth enrolled in CCS or CCS Whole Child Model with additional needs beyond the CCS condition

Children/youth transitioning from a youth correctional facility, or transitioned within the past 12 months

Children/youth involved in Child Welfare / foster care / qualifying adoption or family maintenance services

Children/youth with an intellectual or developmental disability (I/DD) and qualifying additional ECM needs

Birth Equity - pregnant or postpartum youth at risk for adverse perinatal outcomes

PS_Child_POF_Details

Member Last NameKnown medical diagnoses / significant health conditions

Member Last Name

Member Last NameRecent ED visits, hospitalizations, skilled nursing stays, or crisis services

Member Last NameHousing / safety / food / transportation / caregiver / other social needs

Member Last NameReason for ECM referral / what support is being requested

Member Last NameDiscription

Member Last NameOrganization NPI (if applicable)

Member Last NamePerson Referring

Member Last NameTitle / Role

Member Last NamePhone

Member Last NameEmail

Member Last NameDiscription

Member Last NameMember Last NameSource Type - MedicalMedical Provider

Member Last NameMember Last NameSource Type - SocialSocial Services Provider

Member Last NameDiscription

Member Last Name

Member Last NameAdditional comments / information needed to complete the official CenCal ECM referral

Member Last NameMember Last NameInformation is accurate to the best of my knowledge and may be used to determine ECM eligibility.I attest to the statement above.

You do not have to manage everything on your own.

Enhanced Care Management (ECM) provides consistent. coordinated, and long-term support to help individuals and families move toward greater stability, health. and overall well-being. Through personalized Care coordination, community connections, and ongoing follow-up. ECM helps remove barriers that can make daily life overwhelming,

At The Link Family Resource Center. we walk alongside you every step of the way. Whether you need help navigating healthcare systems. finding housing resources. accessing food support. coordinating behavioral health services. supporting your children in school or connecting to community programs our team is here Whelp you feel supported - not forgotten.

Get Connected



Lead Care Manager:
Carmen Del Real



Phone:
805-503-9638



Email:
cdelreal@linkslo.org