Case Management and Disease Management Referral Form

Our Care Team is here to support you and your patients. CMICS Network Providers, please click the button below to refer patients who may benefit from case management services. For any questions or issues, please contact providerrelations@cmpcn.org

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+ Create Referral      (IP Address: 172.20.4.41 )

All other providers, please complete and submit this form (via Email/Fax; see Form) to refer patients who may benefit from case management services. For any urgent referral needs, or further questions, please call Care Integration at 888-670-7262.

Fillable Form

To submit case management exclusions, please click here. Important: Only applicable for CMHN Care Management services (i.e. commercial patients).