CareConnect AZ Referrals and Forms

Patient Referrals

Parents and caregivers can self-refer to the CareConnect AZ program as long as they meet the requirements. 

If you meet the requirements, the next step is to fill out the referral form. The referral form consists of one page of demographic information.

Download the Referral Form (PDF)

Please print the referral form and fax to 602-933-0997.

Many family situations would benefit from care coordination services including:

• A family who is living in a shelter or is homeless
• An overwhelmed parent
• A patient with special health needs who must follow up at specialty clinic(s)
• A teen parent
• A family with domestic violence
• A patient with behavioral health issues
• A parent with behavioral health issues
• A primary caregiver who has lost a job or has other financial issues
• Uninsured/underinsured patients
• A patient with recurrent hospitalizations or ER visits

Contact us

For more information about our program or how we can help, call  (602) 933-0994.