Care Management Registration Form

Care Management Registration

If you would like to refer your child for our program, please fill out the form below and we will contact you. Eligibility for the Care Management program: Your child must be under 21, on Medicaid or Medicaid Managed Care.

To learn more about the Andrus Care Management Program, please email us at caremanagement@jdam.org.

Child's information

Child's name (Last, First, M.I.)

Child's date of birth (example: 02/28/2019)

Child's current address

Gender of child

Caregiver's information

Caregiver's name (Last, First, M.I.)

Language spoken

Email address (if you use one)

Phone number (example: 212-555-1212)

Medicaid CIN #

Eligibility

Choose a single automatically qualifying condition, or 2 or more chronic conditions

Serious Emotional Disturbance (SED) Complex Trauma HIV/Aids 2 or more chronic conditions (include details below):

If 2 or more chronic conditions checked above, include details here

Referral information

Name of person making this referral (Last, First, M.I.)

Agency (if any)

Email address

Preferred phone number (example: 212-555-1212) - optional

Additional comments (if any)

Care Management Registration Form

Care Management Registration

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