EPCS Community Stabilization Referral Form

MEMBER INFORMATION
The Department of Medical Assistance Services Community Stabilization (S9482) Referral Form
Name

Member First NameMember Last Name
Medicaid #
Member Date of Birth

MonthDayYear
Date
Member Plan ID #
Gender
Address

Member Address

Street Address Line 2

City, State, ZIPState / Province

Postal / Zip Code
Member Phone #
Parent/Guardian Name
Parent/Guardian
Phone # (if applicable)
REFERRING PROVIDER INFORMATION
Organization Name*
Provider Phone #*
Provider E-Mail*
example@example.com
Provider Address
City, State, ZIP
Provider Fax #
Clinical Contact Name Credentials
Clinical Contact Phone #
Reason for Referral
Date of Discharge/anticipated discharge

MonthDayYear
Date
By my signature (below), I am attesting that 1) I have performed care coordination activities and collaborated with the Community Stabilization provider as part of my discharge planning 2) the member is in need of Community Stabilization Services as part of a comprehensive discharge plan.

Signature (actual or electronic) referring provider:
Signature*

Clear
Printed Name of referring provider
Title
Credentials (if applicable)
Date

MonthDayYear
Date
Community Stabilization Referral Form Template 09.01.2022
File Upload

Cancelof
Should be Empty:

Parent/Guardian