Referral to Ambulatory Care Management

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A free service that is available to patients and physicians within the AMITA Health Care Network is care management provided by the Ambulatory Care Management Department. Nurses and Social Workers provide telephonic care management to patients that need additional education and/or resources to improve or maintain their current health. The care management staff then become an extension of your care.

Patients to consider would be those with frequent readmissions, multiple chronic conditions, complex hospital discharges, diseases such as uncontrolled diabetes, Anxiety Disorders, Substance Use Disorders, COPD, CHF, just to name a few.

The insurances that case management services are contracted for are: AMITA ACO (MSSP ACO); BCBS ACO; BCBS HMO; BCBS Blue Advantage; BCBS Blue Precision; BCBS Blue Focus Care; Cigna IFP, Cigna CAC/One; Humana, Humana MA, and United Healthcare MA; UNITE HERE HEALTH (UHH).

Referrals can also be made by filling out this form, entering an order in Athena, phone 224-273-0754, fax 872-259-2255 or email CaseManagementFaxing@ascension.org.

Email *

Which insurance does your patient have? *

AMITA MSSP ACO

BCBS ACO

BCBS HMO

BCBS Blue Advantage

BCBS Blue Precision

BCBS Blue Focus Care

Cigna IFP

Cigna CAC/One

Humana

Humana MA

UNITE HERE HEALTH (UHH)

United Healthcare MA

None of the above. I understand that my member does not have an insurance that is part of the AMITA Health Care Network and my member will receive a one time follow up by care management if they were referred by a PCP is part of the AMITA Health Care Network.

First Name *

Last Name *

What is the patient's date of birth? *

TTTT

What is the patient's phone number? *

What is the reason for your referral? *

Please enter a brief description of the current issues faced by your member and specific actions you would like the care management team member to do to support your patient.

What type of issue (s) is your patient facing? *

Frequent Readmissions

Multiple Chronic Conditions

Complex Hospital Discharges

Uncontrolled Diabetes

Anxiety Disorder

Substance Use Disorder

COPD

CHF

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Do you want our care managers to offer your patient enrollment in one of these specific programs? (select all that apply) *

Asthma

Behavioral Health

Complex Care Management

Diabetes

High Risk Maternity

Defer to clinical judgment of care manager/No preference.

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Did you speak to this patient about this referral? *

Yes

Did this patient agree to participate in care management? *

Yes

Contact info

Provide name and contact number of provider making the referral. If you are making a referral and not part of a physician practice please enter your own contact information here.

Referring Provider's Name *

Referring Provider's Phone number *

Referring Provider's E-mail *

Preferred contact method *

Phone

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