Clinical Care Support Program (CCSP) Referral Form

Clinical Care Support Programs

Care Coordination: Short-term transition of care assistance, inpatient transfers, post-discharge needs, transfer from one TRICARE Region to another, etc.

Case Management: Longer-term engagement with beneficiaries who have complex needs. These engagements can be associated with mental and/or physical health diagnoses. This program includes the following sub-programs: Complex Case Management, Mental Health Case Management, Transplants, or Extended Care Health Option (ECHO).

Condition (Disease) Management: Engagement with beneficiaries with specific chronic conditions to provide health and wellness education and guidance to provide the best outcomes and self-management skills.

NOTES:

  • While the Autism Care Demonstration (ACD) is a care support program, a TRICARE approved provider must submit the initial care referral as an authorization/referral with supporting documentation to start the process, which is followed by ACD Care Support program enrollment. Learn more about Autism Care Demonstration.
  • Do not submit a referral for Extended Care Health Options (ECHO) if you are retired, a retired family member, or an active duty service member.


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If you are currently enrolled in a CCSP, do not submit a new CCSP Form. Duplicate submissions will not be accepted or receive a response.

The Information collected with this form is subject to the Privacy Act of 1974 (5 U.S.C. 552A, as amended) and the Health Insurance Portability and Accountability Act of 1996 (HIPAA). This information shall be considered for official use only and protected accordingly. Any individual responsible for unauthorized disclosure or misuse of this information may be subject to a fine of up to $50,000 and/or other sanctions as appropriate.