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Care Coordination Referral Form

Refer a patient to Alabama Care Network by completing the online form below.
For questions, please call
1-833-296-5245 (TTY: 711).

Name*

First Last

Guardian Name (if applicable)

First Last

Medicaid ID*

Date Of Birth*

MM slash DD slash YYYY

Phone Number*

Physical Address*

Street Address Address Line 2 City State ZIP Code

Please include a current medication list and demographic information

Type of Referral

General Care Coordination

Maternity

Quality Improvement Project – Childhood Obesity

Quality Improvement Project – Infant Mortality

Quality Improvement Project – Substance Use Disorder

Hospital Referral?

Yes

No

Discharge Date

MM slash DD slash YYYY

Provider Referral?

Yes

No

Last Visit Date

MM slash DD slash YYYY

Referring Provider Name

Reason for General Care Coordination Referral:

Non Compliance

Yes

No

Non Compliance Options

Clinic Visits

Medication

Other

Non Compliance Options Other

Medication Education

Yes

No

Inappropriate ED Utilizations

Yes

No

Frequent Hospitalizations

Yes

No

Diagnosis Education

Yes

No

Diagnosis

IsNewlyDiagnosed

Yes

No

If Diabetic, A1C Level

Date A1C Level Obtained

MM slash DD slash YYYY

Patient needs behavioral health follow-up

Yes

No

Behavioral Health Follow-up Options

Psychiatry

Substance Abuse

Counseling

Transportation

Yes

No

Other

Yes

No

If Other:

Additional Comments

Referral Source

Referral Source Contact Person Name*

Referral Source Contact Person Email

Referral Source Contact Person Phone*

Referral Source Contact Person Fax

Referring Agency

Date of Referral

MM slash DD slash YYYY

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Alabama Care Network Regions: Mid-State | Southeast

Alabama Care Network Mid-State
417 20th Street North, Suite 1100
Birmingham, AL 35203
1-833-296-5245 (toll-free)
Fax: 205-449-9759
acnmidstate@uabmc.edu

Need help getting the information on our website? Click here .

Alabama Care Network does not participate in any discriminatory practices.

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-294-7780 (TTY: 711)

注意：如果您使用繁體中文，您可以免費獲得語言援助服務. 請致電 1-800-294-7780 (TTY: 711).

Click here for more information about language accessibility and nondiscrimination notices.

You have the right to see any Alabama Medicaid primary care doctor no matter where the doctor is located. You have the right to pick any Alabama Medicaid doctor who delivers babies no matter where the doctor is located. You can only get care coordination services in the county where you live.

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