Independence Care System Member/Participant Referral Form

Please note ICS will close its managed long-term care plan, effective March 31, 2019, and is no longer enrolling new members. On April 1, 2019, we will open up a Health Home program with a continued focused on providing care coordination for people with physical disabilities to be as healthy and independent—in the community—as possible.

To learn more about the program, including benefits and eligibility requirements, click here.

(*) Indicates a required field. “MLTC” refers to Managed Long Term Care.

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If you have additional information about this referral that may be helpful to us, please provide details in the section below and/or attach a file (i.e., prescription, physician orders, face sheet, etc.).

Select fileChange X
(Maximum file size: 10MB; Accepted file types: Excel, JPG, Word, PDF and TIFF)
Select fileChange X
(Maximum file size: 10MB; Accepted file types: Excel, JPG, Word, PDF and TIFF)
To receive confirmation that we have received your submission, please provide your email address below. Due to HIPAA regulations, confirmation emails will only include the date and time that the submission was received and will not include any personal information (such as the individual's name). Please maintain your own record of the information you're submitting for your individual tracking purposes.





If you experience technical difficulties or need clarification on any of the referral form fields, please call us at one of the above numbers.