IC4 Referral

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INDIANA COMPLEX CARE COORDINATION COLLABORATIVE

The Indiana Complex Care Coordination Collaborative (IC4) is housed at Indiana University School of Medicine with a goal to coach and embed nurse care coordinators into primary care practices across the state of Indiana, aimed to provide care coordination for a population of 3,000 children with medical complexity and adults with intellectual disabilities primarily through the use of shared plans of care. This form was created for exclusive use by IC4 partners.
If you have reached this form in error, please return to the INF2F Contact Us page.

* Indicates required field

Referred By *

First

Last

Medical Practice *

Email *

Phone Number *

Contact Name *

First

Last

Relationship to Child *

Contact Demographic Information *

Asian Black or African American Multiple Races Native American / American Indian or Alaskan Native Native Hawaiian or Pacific Islander Some other race Unknown White

Ethnicity *

Hispanic or Latino Non-Hispanic or Latino

Address *

Line 1

Line 2

City

State

Zip Code

Country

Email *

Phone Number *

County of Residence *

Child's Name *

First

Last

DOB *

Preferred Language *

Child Demographic Information *

Asian Black or African American Multiple Races Native American / American Indian or Alaskan Native Native Hawaiian or Pacific Islander Some other race Unknown White

For reporting purposes only, Check all that apply.

Ethnicity *

Hispanic or Latino Non-Hispanic or Non-Latino

For reporting purposes only.

INF2F has Bilingual (Spanish / English) Resource Specialists available to support families in their preferred language.
For families in need of other language support, please note specifics using the "Referral Summary" field at the bottom of this form.

Referral Summary *

Any information that will simplify the process for the family.

By Clicking submit, I verify: *

Verbal or other consent obtained. Information about INF2F provided. The family is expecting contact from INF2F.

Submit

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8435 Keystone Crossing
Ste 190
Indianapolis, IN 46240
P: 844-F2F-INFO (844-323-4636)

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​INDIANA COMPLEX CARE COORDINATION COLLABORATIVE

INDIANA COMPLEX CARE COORDINATION COLLABORATIVE