Orion ISO Consultation Services Referral Form

Participant Legal Name*

First NameLast Name

Participants Medical Assistance Number or PMI#*

Participant Date of Birth*

Date

Participant County of Residence*

Date County Assessment Was Completed*

Date

Is the person served overseeing their own services?*

YesNo

HIDE - Is the person served overseeing their own services?

YesNo

Participant Email*

example@example.com

Participant Phone Number*

Please enter a valid phone number.

Participant Address*

Street Address

Apartment or Unit Number

CityState

Zip Code

Does the participant have a legal representative who will assist with the plan development and program communication?*

YesNo

HIDE - Does the participant have a legal representative who will assist with the plan development and program communication?

YesNo

ARCHIVE - Responsible Party Legal Name

First NameLast Name

Legal Representative Legal Name*

First NameLast Name

ARCHIVE - Responsible Party Email

example@example.com

Legal Representative Email*

example@example.com

ARCHIVE - Responsible Party Phone Number

Please enter a valid phone number.

Legal Representative Phone Number*

Please enter a valid phone number.

Legal Representative Address*

Street Address

Apartment or Unit Number

CityState

Zip Code

Does the person served have a waiver case manager or care coordinator?*

YesNo

HIDE - Does the person served have a waiver case manager or care coordinator?

YesNo

Participant's Responsible Party Name*

First NameLast Name

Responsible Party Email*

example@example.com

Responsible Party Phone Number*

Please enter a valid phone number.

Case Manager Agency

Case Manager Legal Name*

First NameLast Name

Case Manager Email*

example@example.com

Case Manager Phone Number*

Please enter a valid phone number.

Did the participant receive PCA or CSG services within the last year?*

YesNo

HIDE - Did the participant receive PCA or CSG services within the last year?*

YesNo

Does the participant have a waiver?*

YesNo

If yes, what is the waiver type?*

If yes, are they using an Manage Care Organization (MCO) provider?*

YesNo

MCO provider name and contact information.*

HIDE - Does the participant have a waiver?*

YesNo

ARCHIVE - Are you using managed care services?

YesNoUnknown

Kindly indicate your preferred language or format for documentation and meetings:

Questions and Comments*

DISCLOSURE STATEMENT:

By completing and signing this form, you consent to using Orion ISO as your CFSS Consultation Service Provider. You also confirm that you have completed a qualified assessment with your County authorizing CFSS services and have notified your County, Case Manager, or Care Coordinator that have chosen Orion ISO as your CFSS Consultation Provider. Your CFSS start date is contingent upon County approval and, if applicable, the date of your individual assessment.

Participant Name*

First NameLast Name

Participant Signature*

Date of Signature*

Date

Legal Representative Name*

First NameLast Name

Legal Representative Signature*

Date of Signature*

Date

Responsible Party Name*

First NameLast Name

Responsible Party Signature*

Date of Signature*

Date

Orion ISO Consultation Services Referral Form

Orion ISO Consultation Services Referral Form

Participant Information

Legal Representative Information

Responsible Party Information

County Case Manager Information

Service Information

Signatures