IC4 Referral

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 pediatric partners.
If you have reached this form in error, please return to the INF2F Contact Us page.

* Indicates required field

Referred By *

First

Last

Email *

Medical Practice *

Contact Name *

First

Last

Relationship to Child *

Phone Number *

Email *

County of Residence *

Preferred Language *

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.

Child's Name *

First

Last

Child's Age *

Referral Summary *

BY CLICKING SUBMIT, I VERIFY: *

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

Submit

​INDIANA COMPLEX CARE COORDINATION COLLABORATIVE

INDIANA COMPLEX CARE COORDINATION COLLABORATIVE