Care Coordination Referral Form - Sandhills Center - sandhillscenter 2026

1. Click ‘Get Form’ to open the Care Coordination Referral Form in our editor.
2. Begin by entering the 'Referral Date' and your name in the 'Referral Completed by' field. This establishes who is initiating the referral.
3. Fill in the 'LME/MCO' section with the relevant Managed Care Organization details, followed by the 'Follow-up Person of Contact' information for future communication.
4. In the 'Member Information' section, provide comprehensive details about the member including their name, Medicaid county, guardian's name, current placement, and any involved agencies.
5. Clearly state the 'Reason for Referral', ensuring it reflects the member's needs accurately. Include contact information such as phone number and email address for follow-up.
6. Complete diagnosis fields including MH/SA Diagnosis, I/DD Diagnosis, and Medical Diagnosis. If applicable, indicate if there have been recent hospitalizations or crisis services accessed.
7. Finally, ensure that all sections are filled out correctly before submitting. Return the form via fax or email as indicated at the bottom of the document.

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