Provider referrals

Submit a request for services

For case managers seeking 245D, EIDBI, assisted living, and in-home support providers across Minnesota and North Dakota.

This form is secure and confidential. Your information will only be used to source your request within our provider network to find the right provider for your need.

Your information

Case manager full name *

Agency / organization *

Work email *

Work phone *

Request details

Client identifier or initials

Please do not submit full SSNs or unnecessary PHI. Use initials or an internal ID where possible.

Service(s) requested *

245D Basic Support245D Intensive SupportAssisted LivingEIDBI ServicesIn-Home SupportRespite CareHousing StabilizationCase Management ConsultationOther

Client location / ZIP / county *

Urgency level *

Client age range

Preferred language

Insurance / payer / funding source

Preferred provider criteria / specialization

Additional notes

Company website

I confirm I am authorized to submit this referral request and that the information provided is accurate. *

Submitted over an encrypted (HTTPS) connection and shared only with the Elibrium team sourcing your request. Please keep protected health information to the minimum needed.

elibriumllc@gmail.com · (904) 523-8875