Fillable Referral Form Complete this form if you want

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Referral Form Complete this form if you want

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Foundational Community Supports
Referral Form
Complete this form if you want to enroll in the Foundational Community Supports (FCS)
program or refer someone else to the program. Once complete, submit this form to us via
email at FCSTPA@amerigroup.com, or fax it to 1-844-470-8859.
We’ll tell potential enrollees if they may qualify for the program and if there’s a provider
available in their area to work with them. For questions, please call an FCS manager at
1-844-451-2828 (TTY 711) Monday through Friday from 8 a.m. to 5 p.m. Pacific time.
MF-WA-0101-19 www.myamerigroup.com/washington-fcs
*Indicates a required field
Enrollee information
Consider for enrollment in: Supportive housing Supported employment
*Name: *Today’s date:
*Date of birth: ProviderOne number:
Email: Phone #:
Address: *City, State:
Self-referral: Yes No
I give consent to share my information with other health and social care professionals for the purpose of
obtaining supportive housing and/or supported employment services.
Enrollee signature: ________________________________________________________
You do not need to sign to be considered for the FCS program.
Referring party
Please complete the following if not a self-referral.
Name: Phone #:
Agency/Relationship: Email:
Address:
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Referral Form Complete this form if you want

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Completed 29 April 2021

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