Referral – Care Chexx

Requesting Agency

Person Making Request

Your Job Title

Phone Number

Extention

Mobile Number

Client's EHR ID Number

Client's Subscriber ID (If Known)

Client's First Name

Middle Name

Last Name

Suffix

Social Security

DOB:

Age

Race

Gender

Client's Phone Number

Preferred Language

Religious Preference

Discharging Date

Occupation?

County of Service

Financial Worker

Worker Contact Number

Client's Marital Status

Spouse's Name

Spouse's Phone Number

Know Personal Information

Reason For Referral Request

Transportation Needs

Anticipated Length of Stay Needs

Upload Client Documents (If Applicable)

Referral Submission Declaration

By submitting this referral request to Care Chexx Recuperative Care Services, I affirm that all information provided in this form is complete, accurate, and truthful to the best of my knowledge. I understand that any omission or misrepresentation of relevant details may affect the evaluation and outcome of this referral. To be eligible for recuperative care services, an MHCP member must meet all the following criteria. 21 years or older if they have Medical Assistance, or 19 years or older if they have MinnesotaCare. Experiencing homelessness or are unhoused. In need of short-term medical care for fewer than 60 days. In need of assistance with the following covered services.

Care Chexx Referral Form

Referring Agency Information

Make Care Chexx Your Preferred Recuperative Care Provider