Case Management for Children and Pregnant Women requires specific documentation for the comprehensive visit and follow-up visits, the billable components of case management. All forms below are in Word DOC format, unless specified, and may be completed electronically or can be printed. All case management activities must be documented and maintained in a client record. Providers must ensure that documentation for case management activities comply with the requirements of Case Management for Children and Pregnant Women Rule and Policy, Medicaid Policy, HIPAA and all other applicable state and federal rules and regulations. 

CM Forms and Instructions
Case Management Forms
Form Title of Form Instructions
CM-01 Initial Prior Authorization Request  Instructions  
CM-01A Referral and Intake  Instructions 
CM-02 Family Needs Assessment  Instructions 
CM-02A Migrant Information Form  Instructions 
CM-03E-S Service Plan-English/Spanish  Instructions 
CM-03ConE-S Service Plan Consent-English/Spanish  Instructions 
CM-04 Follow-Up Form  Instructions 
CM-04A Follow-Up Documentation  Instructions 
CM-05 Progress Notes   Instructions 
CM-06 Prior Authorization Request for Additional Visits  Instructions 
CM-06A Request to Change Authorization to Another Case Manager  Instructions 
CM-07E-S Referral Form-English/Spanish  Instructions 
CM-08E-S Case Closure Form-English/Spanish   Instructions 
CM-09E-S Case Transfer-English/Spanish  Instructions 
CM-10 Notification of Significant Provider Changes   Instructions 
CM-11 Record of Billed Services (Optional)   Instructions 
CM-12 Authorization to Disclose Protected Health Information - English  Instructions 
CM-12S Authorization to Disclose Protected Health Information - Spanish   Instructions 


Case Management Forms-Vietnamese
Case Management Forms-Vietnamese
Form Title of Form Instructions
CM-03E-V Service Plan-English/Vietnamese  Instructions  
CM-03ConE-V Service Plan Consent-English/Vietnamese  Instructions 
CM-07E-V Referral Form-English/Vietnamese  Instructions 
CM-08E-V Case Closure Form-English/Vietnamese  Instructions 
CM-09E-V Case Transfer-English/Vietnamese  Instructions 
CM-12V Authorization to Disclosure Protected Health Information-Vietnamese  Instructions 


Quality Assurance Forms
Quality Assurance Forms
Form Title of Form
CM-15 Provider Systems Review 
CM-16 Record Review Tool for Providers 
CM-17 Case Manager Observation Tool 
CM-18 QMS Client Referral Log (XLSX)
  HIPAA Example (PDF)


Last updated August 14, 2019