Disease Management AultCare Member Referral Form

Please complete all required* information
I am:
_________________________________________________________________
Health information:
Please allow us to review your referral. Please understand we review referrals on a daily basis and review them as they come into our office. We also receive referrals from many resources. It is very helpful when submitting your referrals for review, that you send as much information for the referral, as possible. This will help us provide you a more prompt response if all information is provided within the referral. This also helps with reviewing and placing members as quickly and as efficiently as possible. This is not a guarantee for member placement. All qualifications still apply.

If you have an emergency, please do NOT submit a referral and call 911.

Thank you,
AultCare
Disease Management Department
330-363-2389
330-363-1153
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