MassHealth Personal Care Management (PCM) Referral Form
This is a HIPAA secure form. The individual seeking services must be actively enrolled in MassHealth Standard or CommonHealth and have a chronic disability requiring hands on assistance with two or more activities of daily living. Please fill out the following form completely and to the best of your knowledge. CLW’s PCM Information & Referral Specialist will contact you within 1-3 business days.
Senior Care Options (SCO) or OneCare Plan members: If the individual seeking services is actively enrolled in a Senior Care Options (SCO) or OneCare Plan, a referral must be made by the SCO or OneCare Plan. SCO or OneCare Plan referrals should be faxed to (508) 519-0401.
Consumer Demographic Information
Eligibility Verification and Insurance Information
Primary Care Physician (PCP) Information