SPEED REFERRAL for Medicaid At-Risk Case Management
FAX: 872-9574

Back to Services, or Home

This form is intended to facilitate the referral process that you, as a professional, are undertaking on behalf of your client. You may print it, fill it out, and fax it to us, or you may fill it out and email it to us by pressing the Submit button below. If you are unsure of eligibility requirements, call RFS at 919-872-7933 to speak to an Intake Specialist.

The following information must be completed in its entirety. Any incomplete information will void the referral.

HINT: Use your mouse or tab key to move from one field to another. Using the Enter/Return key will cause the form to be submitted prematurely!

Client Name:
Address:
City:
State:
Zip:
Phone:
Date of Birth:
Does the client have Medicaid?	Yes No
Medicaid #:	Please call RFS Intake with this info -- 919-713-1556
IMPORTANT: Whom should we contact for further information? (client? caregiver? someone else?)
Contact Name:
Contact Phone:

Eligibility Criteria: Check one, or more if applicable. Client must meet AT LEAST ONE of these criteria in order to be eligible for services.

An individual with only one consistent (reliable but not necessarily living in the home) identified caregiver, who needs personal assistance 24 hours a day with two or more of the activities of daily living (bathing, dressing, grooming, toileting, transferring, ambulating, eating, communicating).

An individual with no consistent identified caregiver, who is unable to perform at least one of the activities of daily living.

An individual with no consistent identified caregiver, who is unable to carry out instrumental activities of daily living (managing financial affairs, shopping, housekeeping, laundry, meal preparation, using transportation, using telephone, reading, writing).

An individual who was previously abused, neglected, or exploited, and the conditions leading to the previous incident continue to exist.

ADLS
Bathing
Dressing
Grooming
Toileting
Eating/Feeding
Ambulation
Transfer

IADLs
Money Management
Shopping
Housekeeping
Laundry
Meal Preparation
Transportation
Communication

Additional comments:

By making this referral, you are certifying that the above information is correct to the best of your knowledge, and that the client is aware of your actions on his/her behalf. If you have any questions related to this referral, please call an Intake Specialist at 919-872-7933.

Your Name:
Organization:
Your Email:
Phone# where message can be left for you (no pagers, please!):