Care Coordination Resources
Minnesota Senior Health Options (MSHO)
Care Plan Letter
Care Plan Signature Letter
Change in Contact Info for Care Coordinator
Change of Care Coordinator Letter
Member Change Letter
Plan of Care Letter to Primary Care Provider
Provider Care Plan Cover Letter
Provider Care Plan Summary Letter
Unable to Reach Member Letter
Welcome Letter - Member in Nursing Home (Revised 5-9-2019)
Welcome Letter - Member on CAC, CADI, DD, or TBI Waiver
When To Call Your Care Manager
Additional or Substitute Home and Community Based Service Exception Request Form (Revised 7.23.2019)
Care Coordination Appointment Reminder Form
Collaborative Care Plan-PDF (Revised 9.23.2020) | Collaborative Care Plan-WORD | Instructions
Customized Living Verification Code Form | Customized Living Verification Code Guidelines
Death Notification Form
Dental Kit Form
Health Connect 360 Referral Form
Home Health Communication Form | Example
Institutional Care Coordination Documentation (ICCD) Form-WORD
Institutional Care Coordination Documentation (ICCD) Form-PDF (Revised 3.15.2019)
Medication Toolkit Order Form (New 1.1.2020)
MOM’s Meals MSHO Supplemental Benefit Form (New 1.1.2020)
MSHO AA/NA Ride Request Form (1.17.2020)
MSHO ILS Supplemental Benefit Form (Revised 6.23.2021)
Memory Kit Order Form (New 1.1.2021)
MSHO Supplemental Benefit Form (Revised 8.19.2021)
Nursing Home Face Sheet
Part C Log (Revised 6.30.2021) | Part C Log Tip Sheet (Revised 1.1.2021) | MSHO Tips for Completing Part C Log (New 6.15.2020)
Reemo Smartwatch Order Form (5.10.2021) | Reemo Smartwatch Overview
Refusal Care Plan Form - WORD
Refusal Care Plan Form - PDF
Release of Information Form
Request to Exceed Case Mix Cap (Revised 9.6.2019)
Strong & Stable Kit Order Form (Revised 11.12.2019)
Transitional Health Risk Assessment Form - Word
Transitional Health Risk Assessment Form - PDF
Unable to Contact Outreach Care Plan Form - PDF | Unable to Contact Outreach Care Plan Form - Word
Waiver Service Approval Form (Revised 8.20.2021)
- Used by the PCA agency when a member is due for their annual PCA assessment and must send it 60 prior to the end of the PCA authorizations.
- Used when a DTR needs to be issued for services or an assessment (i.e., Early assessment, Refusal or Unable to reach).
- Member has selected a PCA provider agency.
- Used to approve or DTR extended PCA services.
- Used when the CC is reporting a change or new PCA provider agency.
- Approve 45 day temp start/Increase of PCA services.
PCA Coverage Policy (The PCA provider agency is required to notify UCare of a provider change however, the care coordinator may report this information to UCare in behalf of the provider).
- Used by providers when a member changes to a different PCA provider agency.
- Used by providers when a member previously had not selected a PCA provider agency at the time of the assessment but has now made their selection.
- Used to request a transfer of a PCA Authorization from another health plan to UCare.