Medical Referral Form

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Medical Referral Form/FEP
Blue Cross Blue Shield Michigan to NDBH
Referral Date:
Member Name:
Member DOB:
Member ID#:
Member Phone#:
Medical CM’s Name:
Medical CM’s Phone #:
Medical CM’s Email:
Is Member currently open in any programs with the BCBS CM?
If “yes”, which programs?
Member’s PCP’s Name:
PCP’s Phone #:
PCP’s Fax #:
Is Member under age 18?
Does Member have a Legal Guardian? (Name and Phone # if applicable):
Is Member aware of referral to NDBH?:
Did Member agree to be contacted by NDBH?:
Best time to reach Member:
Requesting Service: Screening and Referral Integrated Case Management Other
*explain Other
Reason for Referral:
Describe details of referral reason:
List any Medical Conditions (describe if necessary) of Member:
What is Primary Concern?:
Please Email to: & Michigan_CM@ndbh.com
Subject Line: Referral From Michigan FEP Medical Plan

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