Clinical Care Support Program Referral Form

TriWest offers Clinical Care Support Programs that are specifically designed for those individuals who...

TriWest offers Clinical Care Support Programs that are specifically designed for those individuals who would benefit from additional medical management assistance. Our programs provide support and education to improve beneficiary health outcomes. These programs include: Care Coordination, Case Management (complex, transplant, ECHO and Autism), Condition (Disease) Management, and Tobacco and Vaping Cessation Support. To obtain more information about these programs, please explore by clicking the items in the “blue” box.

To refer a beneficiary for one of our programs, complete the Clinical Care Support Program Referral Form. Once submitted, our clinical staff will review your request, determine eligibility and begin appropriate program outreach through the identified contact information provided. We look forward to being part of the beneficiary’s health journey.

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Fields with an asterisk (*) are required.

Beneficiary First and Last Name *

Beneficiary Date of Birth

Program*

Beneficiary Contact Preference*

Describe the Reason for Referral *

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Beneficiary First and Last Name *

Beneficiary Date of Birth *

Program*

Sub-Program*

Beneficiary Contact Preference*

Beneficiary Phone*

Beneficiary Email*

Beneficiary - Portal Notifications *

Describe the Reason for Referral*

Please be assured that TriWest takes all concerns seriously and will thoroughly investigate the matter and take all appropriate actions. Due to federal and/or state privacy regulations, we are unable to share the results of our investigation or actions taken as it pertains to a clinical quality program.

The Information collected with this form is subject to the Privacy Act of 1974 (5 U.S.C. 552A, as amended) and the Health Insurance Portability and Accountability Act of 1996 (HIPAA). This information shall be considered for official use only and protected accordingly. Any individual responsible for unauthorized disclosure or misuse of this information may be subject to a fine of up to $50,000 and/or other sanctions as appropriate.