Referrals

Refer a participant for care.

We’re glad you chose Summer Rose Care — we look forward to working with you. To get started, please complete this form (one form per person receiving services). After you submit, our team will contact you with next steps.

About you

What is your relationship to the participant?*How did you hear about Summer Rose Care?*

Is the participant their own representative?*

Can the person receiving services make their own decisions about this program? An authorized representative means a person who is authorized by a participant to act on their behalf in matters involving the application for assistance or participation in the program.

YesNoUnsure

Participant information

Participant's first name*Middle nameParticipant's last name*

Participant's date of birth*Medical Assistance (MA/PMI) number

Leave blank if unknown.

Participant's birth sexParticipant's preferred pronoun(s)

Participant's phone number*

Address

Physical address line 1*Physical address line 2

City*State*ZIP code*

Participant's physical address is the same as mailing address?*

YesNo

County & funding

Participant's county of residency?*County responsible for funding (financial responsibility)*

Does the participant have a spenddown or waiver obligation?*

MN Definition of Spenddown: Cost-sharing approach that allows Medical Assistance (MA) eligibility for people whose income is greater than the applicable limit.

YesNoUnsure

Does the participant currently use services with Summer Rose Care or has used services in the past?*

Currently utilize services with Summer Rose CarePreviously have utilized Summer Rose Care servicesNew to services with Summer Rose Care

Representative contact

Does the participant have more than one responsible party / participant representative?*

YesNo

Email of primary responsible party / participant representative*Confirm email of primary responsible party / participant representative*

Does the responsible party / participant representative need an interpreter?*

YesNo

What language does the primary responsible party / participant representative prefer?*

Additional information

Other items you would like us to know?

Refer a participant for care.

About you

Participant information

Address

County & funding

Representative contact

Services information

Additional information