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Case Management & Health Promotion Referral Form

Our Case Management and Health Promotion programs offers dedicated Case Management services to members with challenging health and/or social conditions that prevent them from reaching their optimal level of health and wellness.

The program is free, voluntary and member-centered.

For any questions contact Chorus Community Health Plans at (414) 266-3173 or email at healthpromotion@chorushealthplans.org.

On the form below, * indicates required fields.

Member Information and Demographics

Complete this field if member is a minor or has a court ordered guardian.

Medically Tailored Meals

Clinical History

Utilization Management

Referral Source