Sourcewise Enhanced Care Management Interest Form

The Sourcewise Enhanced Care Management (ECM) provides a whole-person approach to care that addresses high-need Medi-Cal members’ clinical and non-clinical circumstances. ECM is intended for the highest-risk individuals with complex medical and social needs.

Who are you applying for?YourselfSomeone Else

Applying for someone elseFamily MemberFriend / NeighborClient / Patient

Your name, if applying for someone else

Your phone number, if applying for someone else

Please fill out the client Information below.

First Name *

Last Name *

Email

Phone Number *

Address *

Zip Code *

Date of Birth *

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What does the person need help with?

Medi-Cal ID#

Does the individual have a managed Medi-Cal plan via (choose one):Santa Clara Family Health PlanAnthem Blue CrossNo

Is the individual at least 18 years old?

• Yes
• No

Please check the services below where you would like to receive more information. *

• Information & Awareness (locate resources in Santa Clara County);
• Health Insurance Counseling (Medicare);
• Digital Inclusion (iPad Technology Program);
• Senior Employment Services;
• Caregivers Network;
• Meals on Wheels;
• Public Authority Services;
• Dignity at Home Fall Prevention;
• Sourcewise Transit Service;
• Other;

Other Services

How did you find out about this program? *Postcard in MailEmail from SourcewiseCase ManagerFriend or Family MemberSocial Media211Second HarvestSanta Clara County

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