CIP ARMHS Program

Referral Form

ARMHS Programs Referral Form

**This completed form can be faxed Attn: Shayla Eubanks,Lead Service Coordinator at 612-547-0556 or

e-mailed to ; (612) 362-4452. Please have the service applicant sign and then return the enclosed Release of Information with the referral form. Copies of a diagnostic assessment (within 6 months) and other collateral mental health documentation supporting their medical necessity could facilitate eligibility process.

Referred by: Self-referral / Phone number:
How do you know this individual?

Personal Information

Name:
Does person require an interpreter? What language?
SS#(required) : / DOB: / Working(required)Phone number:
Address:
City: / Zip code:
Insurance/PMI/MA#:
Spend down? Yes No If yes, has the person agreed to pay the spend down for ARMHS? Yes No
*See attached form to be completed for each referral
Mental Health Diagnosis ICD-10 code/description:
Emergency Contact (relationship):

Team Members

A psychiatrist? Name: ______Clinic/Agency: ______
A therapist?Name: ______Clinic/Agency: ______
A Care Coordinator? Name: ______Clinic/Agency: ______
A CADI/TBI/Elderly Waiver Case Manager? Name: ______Agency: ______
A rep-payee? Name: ______Contact info: ______
Other provider? ______
Helpful contact numbers or email addresses are appreciated.

Referral

Reason for referral/Goal Suggestions:
Does this person have any history of violent behavior and/or criminal history? Yes No
Describe:
Are there any known spiritual or cultural considerations? Yes No
Describe:
Are there any possible safety concerns present in the home, including bedbug infestation? Yes No
Describe:
Is there a gender preference regarding the assigned staff? No Male Female
Selection could affect availability of staff for assignment.
Any other relevant information:

Participant Agreement for Payment of Medical Spenddown

Participant Name: ______Date: ______

I understand that I have a Medical Spenddown in the amount of $ ______per month.

Once this amount is satisfied, my medical psychiatrist services will be completely covered.

(This amount does not include any co-payments that I may have for medication).

I will use this service of a representative payee:

Yes

If yes, the Rep Payee is, Name: ______

Address: ______

______

I agree to pay CIP my monthly spenddown amount and I understand that if payment is not made to CIP; my services may be terminated.

______

Signature of ParticipantDate

NA—Participant does not have a spenddown

Return to:

Community Involvement Programs

1600 Broadway Street NE

Minneapolis, MN55413

*Fax: (612) 547-0556