TRAINING REFERRAL PROVIDER KIT

Referrals
When sending a referral to NAZCARE, please include a copy of the following:
1) Signed and dated Release of Information naming NAZCARE
2) NAZCARE Referral form
3) Diagnosis assessment
a. Dated within the last 12 months
b. Signed by a BHP
c. Diagnosis code(s) noted
4) Treatment plan (ISP)
a. Dated within the last 12 months
b. Signed by a BHP
c. Peer Support Training Specifically noted

These documents should be sent to NAZCARE’s HIPPA compliant fax

602-535-3230
 NAZCARE Referral and Update Form
Failure to complete this form may result in delay of services

Check for New Referral ☐ or Update ☐ Date of Referral/Update_____________________________________

Check the NAZCARE Wellness Center referring to:

☐ New Directions ☐ Friends ☐ Power ☐ Discovery ☐ El Bienestar ☐ New Hope ☐ Rising Star ☐ Serenity Circle

Will Member require Deaf or Hard of Hearing (D/HH) services? Yes ☐ No ☐

Client Referral Information

Name of Member Date of Birth

Street Address

City and Zip Code AZ

Telephone Number ( )

AHCCCS Number CIS ID

Check to verify that all required elements necessary to process this referral/update are included:

☐Release of Information listing NAZCARE

Diagnosis Assessment Treatment Plan
☐ Dated within the last 12 months ☐ Dated within the last 12 months
☐ Signed by a BHP ☐ Signed by a BHP
☐ Diagnosis Code(s) noted ☐ Specific Services noted

Check the recovery services for this referral/update below:

☐ Peer Support ☐ Adult Living Skills ☐ Supportive Employment ☐ Peer Support Training
☐ Transportation ☐ Family Support ☐ In-Patient Peer Support Groups

Numeric Diagnosis

Recovery Goal(s) for Referral

Referring Agency Information

Referring Agency Name and Location

Case Manager Name

Case Manager Telephone Number

Case Manager Email Address

For NAZCARE use only

New Annual Update RBHA Eligibility Date Dis/Term

EMRN RA Receipt Return Date

Referral Complete Y N

Fax to Claims Department – HIPPA Fax (602) 535-3230

NAZCARE Referral and Update Form IO-CL-0004-FM