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If the referral is for a youth between the ages of 18-21, please complete the following and check all that apply.
If child is under 18 years of age STOP, do not continue this referral.
Please DO NOT COMPLETE THIS FORM. Contact your local LDSS for further direction.
Must meet either:
Make sure to specify the diagnosis. E.g. - Serious mental illness - 296.8 Bipolar Disorder NOS E.g. - Other chronic conditions - COPD
Give some detailed information concerning member's risk factors
E.g. - Member is at risk for hospitalization due to non-adherence with medication
Provide any additional information that may be helpful in assignment to a care management agency
Please click on attachment A to view the list of agencies and organizations that your information may be disclosed to, only when necessary for your referral to be processed. Attachment A for Central Region Attachment A for Finger Lakes Region Attachment A for Southern Tier Region Attachment A for Western Region