Pediatric Care Management Referral Form
For children aged 0-3 years, refer directly to CDSA if concern is prima
rily developmental
Referral & Patient Information
Referral Date: Referral Source/Agency:
Referral Name: Referral Phone:
Referral Title: Referral Fax:
Patient Name: DOB:
□ Male □
Patient Social Security Number:
Parent/Guardian informed of referral:
Yes
No
Physical Address: County:
Parent/Guardian Name: Parent/Guardian Phone:
Primary languages: □ English □ Spanish □ Other _____________ Needs interpreter: □ Yes □ No
Please include a current list of medications to help us provide
more complete services.
□ No medications
Referrals for children aged 0-5 years
Please consider referring to the CMARC (Care Management for At Risk Children)/C4CC (Care Coordination for
Children) program at the health department. A referral form can be found here: http://ccnc.care/cc4creferral
.
Referrals for children aged 5-20 years*
□ Medicaid ID: □ Transportation needs: □ Child in foster care program
□ Behavioral health concerns: □ Asthma: □ Diabetes:
□ Child exposed
to toxic stress
(please specify):
□ Current domestic/family violence
□ Neglect
□ Homeless/living in shelter
Parental rights terminated in past
□ Health/safety needs
□ Unsafe/unstable environment
□ Parent/Guardian with substance
abuse/mental health condition
□ Child w/ special health care needs – chronic (>12 mos.) physical/behavioral/emotional condition (please specify):
□ CPS/Foster care involved; if yes, Phone: □ Needs medical home
□ Repetitive use of ED services/multiple hospitalizations □ Pharmacy/medication needs:
□ Other (please specify):
*Must have Community Care of North Carolina/Carolina ACCESS (CCNC/CA) or NC Health Choice
Ple
ase fax completed form to 1-833-282-0884. If you have questions about your referral,
call 1-877-566-0943 or visit CCNC’s website at www.communitycarenc.org.
