Medicaid Expansion Crisis Line Utilization Form

Please complete the following form for any Medicaid Expansion Member utilizing the Crisis Line to access the Mobile Crisis Team, the Emergency Room or Detox.

Member

* Required fields

Member First Name

Member Last Name

Member Date of Birth

Member ID Number

Member Phone Number

Case Management Referral Yes

Summary of the Member's Needs

Submitter

Submitter First Name

Submitter Last Name

Submitter Contact Number

Our Partners in Health:
Members
Employers
Providers
Producers

Fargo (Headquarters)
4510 13th Ave. S.
Fargo, N.D., 58121

Non-Discrimination Notice
Español
Deutsch
繁體中文
Oroomiffa
Tiếng Việt
Ikirundi
العَرَبِيَّة
Kiswahili
Русский
日本語
नेपाली
Français
한국어
Tagalog
Norsk
Diné Bizaad