Care management enrollment form

Use this form to request assistance for you or someone else from the Prevea360Health Plan Case Management team.

If you are referring an adult for services, we will call the adult member.

What is your relationship to the Prevea360 Health Plan member who needs care management?

Member Name

Name of person making referral, if not the member listed.

Phone number

Birth Date

Member Number (see insurance card)

Primary care provider (name or location)

Which care management services are you interested in?

Reason for referral

Briefly describe your case management needs.

Please confirm