Case Management FOLLOW-UP DOCUMENTATION CONTINUED Form

CM-04A INSTRUCTIONS 04/13

CASE MANAGEMENT FOLLOW-UP DOCUMENTATION CONTINUED FORM INSTRUCTIONS FOR COMPLETION

This is an optional supplemental page which, if used, must be attached to a completed CM-04 Follow-up form. The case manager must sign and date the CM-04 that accompanies this form.

If you are using the electronic version of the CM-04, it will allow space to continue typing information and therefore, this form would not be necessary.

NAME: enter the client’s first and last name. MEDICAID NUMBER: enter the client’s Medicaid number. If the client’s Medicaid is pending, enter “pending”. CONTINUATION OF FOLLOW UP NUMBER: check box for the appropriate follow-up number.

SUMMARY OF FOLLOW-UP CONTACT CONTINUED Document continuation of the activities that occurred during the follow-up contact.