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.

Today's Date

Referral Source

Referral Source Name

Referral Source*

Self

Other (explain)

If other, please explain

Phone*

Email*

Alternative Phone

Consumer Demographic Information

Consumer First Name*

Consumer Last Name*

Date of Birth*

Address*

Street Address Address Line 2 City State ZIP Code

Are you residing in a long-term care facility?

Yes

If yes, what is the name of the facility?

If yes, what is your anticipated discharge date?

Email*

Phone Number*

Alternative Phone

Do you speak English?

Yes

Primary Language*

Communication Needs?

Legal Guardian Name (Parent if under 18 years old or Court Appointed)

Guardian Email

Guardian Phone

Guardian Alternative Phone

Eligibility Verification and Insurance Information

MassHealth ID Number*

Primary medical diagnosis & permanent disability*

Date of Onset*

Areas needing physical assistance (activities of daily living)*

Mobility/Transfers

Toileting

Medications

Eating

Dressing

Bathing/Grooming

Passive Range of Motion

Incontinence

Other/Explain

What other areas of physical assistance do you require?

Are you currently receiving any services in the home?

What other service(s) are you currently receiving?

Primary Care Physician (PCP) Information

PCP Name*

Phone*

Fax

Address*

Street Address Address Line 2 City State ZIP Code

Date of Last Visit with PCP*