Care Coordination – Ambulatory Self-Referral Form The following self-referral process will help us establish if we are able to assist with your needs in the community. Please answer the following questions to determine if you meet the criteria for one of our Care Coordinators to help with the identified needs. Do you have a primary care doctor with MCR Health?(Required) Yes No In order to receive Care Coordination services you need to have a primary care doctor with MCR. Please contact one our clinics to become established as a patient. Click on the link to go to page and see what the closest clinic to you. Are you over the age of 18?(Required) Yes No Please note that Ambulatory Care Coordination assists patients that are 18 or older. We are not able to assist at the current time. However, you might want to take to your care provider to be referred for more assistance Which of the following counties are you currently located (Please note services are provided only within the listed counties by our Care Coordination Ambulatory staff)?(Required) Manatee Sarasota Desoto Are you struggling or experiencing a hard time with any of the following (please check all that apply):(Required) Transportation (I am unable to go to doctor appointments/or shopping) Food (I have hard time obtaining food) Financial difficulty (I am unable to pay rent/utilities/etc.) Social Support (I need help at home) Medications (I am unable to afford my medications) DME (I am in a need of durable medical equipment such as shower chair/ramp/walker/etc.) Other Please identify a need that was not listed to see if we can helpPlease provide your contact information in order for one of our staff to outreach and start assisting with your needs! The Care Coordination department is looking forward of working with you. Thank you for picking MCR Health as your health care provider. Name(Required)DOB(Required) MM slash DD slash YYYY Contact Number(Required)CAPTCHAOnce you are finished, please scroll down and click "Submit" below.