Pathways/MATCH Referral Form

Serving Pathways to Better Health & Managing Asthma Through Case Management in Homes (MATCH Program)
Ingham Health Plan Corp serves as a vehicle to connect those in need - including infants, children, parents, families, caregivers and adults with chronic health conditions - to health and social service resources and programs to help better their lives and improve health.
Referral Source Information
Referral is for
Is the client aware of this referral?
Person Completing Form
Referring Agency
Type of Referral Agency
Phone Number
Format: 000-000-0000.
Fax Number
Format: 000-000-0000.
Email
example@example.com
Best way to reach?
Client Information
First Name
Last Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Preferred Name, if applicable
Gender
Preferred Pronouns, if known
Due Date (if pregnant)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address

Street Address

Street Address Line 2

CityState

Zip Code
County
Phone Number
Format: 000-000-0000.
Email
Best way to reach?
Primary Spoken Language
Does this client need an interpreter?
Insurance & Health Information
Insurance Type (check all that apply)

Other
Medicaid/HMP Plan Name
(For Pathways referral: if not McLaren, member should contact health plan's customer service # on back of insurance card for available programs and support.)
Medicaid #
Date Medicaid Confirmed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
You've indicated Insurance Type as Medicare. Pathways to Better Health can only serve clients with McLaren Medicaid. You could try contacting Tri-County Office on Aging 517-887-1440 or Pathways to Care 517-272-4123 to see if they are able to assist.
Medicare placeholder- no longer using
placeholder
Date medicare confimed placeholder - no longer using

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
IHP HPMS #
Date IHP Confirmed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Plan Name & Member #
Primary Doctor Name (or Pediatrician if referral is for a child)
Primary Doctor Phone Number
Format: 000-000-0000.
# of ED visits in the past 12 months
# of hospital admissions in the past 12 months.
Chronic Health Conditions (check all that apply)

Other
Legal Guardian Information
First Name
Last Name
Relationship to referred

Other
Phone Number
Format: 000-000-0000.
E-mail
Reason(s) for Referral
Adult Main Reason for Referral
Child Main Reason for Referral
Other Reasons for Adult Referral (if applicable, check all that apply)

Other
Other Reasons for Child Referral (if applicable, check all that apply)

Other
Access to Community Resources for

Other
Any Additional Information
Please provide any additional information regarding the reason for this referral that may be helpful in determining eligibility into our programs. Please explain any concerns you may have checked off.

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2111 Univeristy Park Dr Suite 100 | Okemos, MI 48864 | P: (866) 291-8691 | F: (517) 394-4590

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Serving Pathways to Better Health & Managing Asthma Through Case Management in Homes (MATCH Program)

Referral Source Information

Client Information

Insurance & Health Information

Legal Guardian Information

Reason(s) for Referral

Any Additional Information