COORDINATION OF CARE AND SERVICES AGREEMENT (CCSA)

COORDINATION OF CARE AND SERVICES AGREEMENT (CCSA)

Page 1
Agency Staff/Personnel Completing Care Referral: *
Secure Fax Number
Section A: Acceptance of Care and Coordination of Services
Name

First NameMiddle NameLast Name
Birth Date

MonthDayYear
Client ACCEPTS Coordination of Care and Services Agreement:

YesNo
Reason(s) Client Refused:

Client is already in care and does not need coordination of care and services.Client is unable to be located or contacted.Client did not provide a reason.Other
Medical Provider Name:
Date Refused

MonthDayYear
Print Full Name
Date Refused

MonthDayYear
Current Gender

MaleFemaleTransgender M to FTransgender F to MDeclinedOther
Race:

Black/African AmericanWhiteAsian/Hawaiian/Pacific IslanderAmerican Indian/Alaska NativeDeclinedOther
Ethnicity:

HispanicNon- HispanicDeclined
Testing/Diagnosis Information:

HIV NegativeHIV PositiveHepatitis C (HCV)
Negative Test Date:

MonthDayYear
First Diagnosis Date:

MonthDayYear
Diagnosis Date:

MonthDayYear
Address

Street Address

Street Address Line 2

CityState

Zip Code