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.

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Who are you applying for? *YourselfSomeone Else

Your name, if applying for someone else

Your phone number, if applying for someone else

Relationship to Client? *

Please fill out the client Information below.

First Name *

Last Name *

Email

Phone Number *

Address *

Zip Code *

Would you like to receive future updates and mailings from us? *

• Yes
• No

Date of Birth *

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Sex at birth? *MaleFemalePrefer not to respond

Sexual Orientation *Straight/HeterosexualBisexualGay/Lesbian/Same-Gender LovingQuestioning/UnsureNot listed, please specifyPrefer not to respond

Please Specify *

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

Have you ever served in the US military? *

• Yes
• No
• Prefer not to respond

In affiliation with someone who is serving or has served in the US military? *

• Yes
• No
• Prefer not to respond

If affiliated, would you like us to share your contact details with VA for additional assistance? *

• Yes
• No
• Prefer not to respond

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

• Information & Awareness (locate resources in Santa Clara County);
• Caregivers Network;
• Digital Link (iPad Technology Program);
• Health Insurance Counseling & Advocacy Program (Medicare);
• Meals on Wheels;
• Public Authority Services;
• Senior Employment Services;
• South County Services;
• 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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