Submitting a Preauthorization Request is a simple alternative to calling our office. Complete one of the forms (select the appropriate one depending on the requested service) and submit the completed form along with pertinent/requested clinical information to ICM for review.

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ICM Preauthorization Request Form Submit completed forms and clinical information outlined below by upload* to our secure server found through the red “click to upload files” button at https://www.innovativecare.com/, by fax to 503-654-8570, or by secure email to [email protected].

If you have patients that would benefit from the additional support provided by ICM, call 1.800.440.5071 x2024, or fax a completed ICM Referral Form to 866.361.7242. Our certified Community Health Workers (CHWs) serve as ambassadors for the HUSKY Health program and help families access community resources for the services they need.

Management (ICM) Referral Fax to: Intensive Care Management at 866.361.7242 Member’s Name: DOB: HUSKY Health ID #: Gender Identity/Preferred Pronouns: Address: Home Phone: Cell Phone: Primary Language: Best time to contact the member: Diagnosis: Provider Name: Provider Phone Number: Provider Fax Number:

现在大部分期刊通用的利益冲突表模板是适用的ICMJE 提供的模板，一般投稿前可以到期刊 submission guideline 有下载链接。 以下，按照 无专利+有无基金支持，提供COI form 的样本作为参考. 2, 第2页和第3页的填写——no funding and no patent. 3, 第2页和第3页的填写——funding and no patent. 4, 如何区别利益. Section 2 和section 5 都是对有利益关系的来源进行披露。

Innovative Care Management (ICM) is your provider of medical management services and honors your rights and responsibilities as a plan participant. Please see your health plan document for complete information on your benefits and eligibility as well as your rights and responsibilities.

ICM Referral Form Inpatient Acute Rehabilitation For all inpatient admissions requests to Acute Rehabilitation and Chronic Disease Hospital; complete and fax the form to 203.774.0551 .

ICM Preauthorization Request Form Submit completed forms and clinical information outlined below by upload* to our secure server found through the red “click to upload files” button at https://www.innovativecare.com/, by fax to 503-654-8570, or by secure email to [email protected].

Intensive Case Management (ICM) Referral Form . 315 SW Fifth Ave, Portland, OR 97204 • 800 -224-4840 • careoregon.org . Instructions: Please complete all fields below as indicated. Select the appropriate level of care and attach relevant clinical documentation, along with any additional information that will not fit on the form.