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Online: Adult Mental Health Case Managment Referral Form

  1. Private Insurance ***Need Copy of front and back of insurance card***

  2. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

  3. By electronically signing this you acknowledge that you have spoken to the client regarding the referral and have a signed release to submit the referral on file.

  4. Additional information:

    * Attach a diagnostic assessment that has been completed in the last 180 days. * Adult Mental Health Case Management is based upon eligibility outlined in MN Statute 245. *Screening for Case Management eligibility is competed twice a week. * INCOMPETE REFERRAL FORMS WILL BE RETURNED FOR COMPLETION TO THE REFERRING AGNECY.

  5. Leave This Blank:

  6. This field is not part of the form submission.