• COORDINATION OF CARE AND SERVICES AGREEMENT (CCSA)

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  • Section A: Acceptance of Care and Coordination of Services

  • Client ACCEPTS Coordination of Care and Services Agreement:
  • Reason(s) Client Refused:
  • Current Gender
  • Race:
  • Ethnicity:
  • Testing/Diagnosis Information:

  • COORDINATION OF CARE AND SERVICES AGREEMENT

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  • Confidential Information (Check all that Apply) Allowed to be Shared:
  • May Be Released To:
  • Approved Contact Methods (Check all that apply): In Person (at the address below)

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  • Street Address Postal Mail/Letter (at the address below, if different than above)

  • Home Phone: Cell Phone: Work Phone: Email:

    May we leave a message/text message? May we leave a message?

    Section D: Linkage to Care and Services Agency Linking Client to Care and Services (may be the same as the originating agency):

  • Format: (000) 000-0000.

  • Client is already in medical care but would like coordination of other services

  • ACTION: FAX ENTIRE FORM TO THE AGENCY ABOVE IF REFERRING TO AN EXTERNAL AGENCY FOR LINKAGE SERVICES

  • Section E: Referrals to Care and Services and Confirmation of Linkage If your agency has received a referral for linkage services OR if you are the original agency who will also be providing linkage services for the client, please complete this section: (REQUIRED) Medical Care Referral: (If client is already in medical care then list current medical provider)

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  • ACTION: PLEASE SECURELY FAX ALL COMPLETED FORMS TO THE ORIGINATING AGENCY (IF APPLICABLE) AND TO THE VDH CENTRAL OFFICE AT (804) 864-7970

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