Wraparound Care Coordination Referral Form – Tri-County Health Network

TCHNetwork’s Wraparound Care Coordination focuses on helping adults who are uninsured, have private insurance, CICP, or Medicare with multiple complex needs get connected to community supports and services.

To refer someone to Wraparound Care Coordination, please submit the form below. Once your request has been received, our team will reach out to you within 1 business day. Thank you!

Eligibility Requirements

18 years old and up (not in another Case Management Program)
Uninsured, private insurance, CICP, or Medicare
Cannot be on Medicaid, (Medicaid members can be referred to TCHNetwork’s Medicaid Care Coordinator)
A patient with the Basin Clinic (there is a plan to expand in the spring to all West End residents)

When in doubt, ask. Contact Amy Rowan at oc-montrose@tchnetwork.org or 970.614.7311 M-F 8-5 for assistance.

Verification of Client Consent

Client is aware and agrees to being referred to for Wrap Around Care Coordination?* YesNo

Please inform the client and obtain consent prior to proceeding.

Referring Party/Agency

First Name*

Last Name*

Agency Name (if applicable)

Relationship to Client*

Please specify:

Phone*

Email*

Date of Referral*

Client Information

First Name*

Last Name*

Date of Birth* (Can be typed in by hand)

Age

Insurance*

Please specify:

Primary Phone*

Physical Address Line 1*

Physical Address Line 2

City*

State*

Zip Code*

What are the immediate concerns and needs to be addressed?*

Involved Parties

Please list spouse, partners, agencies, and other supports that are involved with the client and family.

Name

Relationship

Agency (if applicable)

Phone

If you get a message that says, “There was an error trying to send your message. Please try again later,” just click “Submit” again.

If you continue to get an error message, or have any other questions please contact Amy Rowan at oc-montrose@tchnetwork.org or 970.614.7311 M-F 8-5 for assistance.

For questions and assistance, please contact Amy Rowan at oc-montrose@tchnetwork.org or 970.614.7311 M-F 8-5. Thank you!