Get the free Care Coordination Referral Form - Primary Health Tasmania

Care Coordination Referral Form Chronic Disease and Aboriginal Health Programs Select appropriate service location Chronic Disease referrals to: Hobart Fax: 03 6224 4981 Silverstone Fax: 03 6425 8588

How to fill out care coordination referral form

How to Fill out a Care Coordination Referral Form:

1. Obtain the care coordination referral form from the relevant healthcare provider or agency.
2. Begin by filling out the patient's personal information, including their name, date of birth, address, and contact details. This ensures accurate identification and communication.
3. Provide the patient's insurance information, including the name of the insurance company, policy number, and any additional details required.
4. Indicate the reason for the care coordination referral, briefly describing the patient's medical condition or the specific service needed.
5. Include details about the referring healthcare provider or agency, such as their name, contact information, and any pertinent professional credentials.
6. Specify the preferred care coordinator, if applicable, or leave it blank if the patient has no preference.
7. Attach any relevant medical records or documentation that supports the need for care coordination.
8. Review the completed form for accuracy and ensure all required fields are filled in.
9. Sign and date the form, indicating your agreement with the provided information.
10. Submit the care coordination referral form to the designated recipient, following the instructions or guidelines provided.

Who Needs a Care Coordination Referral Form:

1. Patients with complex medical conditions that require multiple healthcare providers and services may benefit from care coordination.
2. Individuals with chronic illnesses or disabilities that require ongoing management and support could benefit from care coordination services.
3. Patients transitioning from one healthcare setting to another, such as from a hospital to a rehabilitation facility, may require care coordination to ensure a smooth transition and continuity of care.
4. Older adults who require assistance with managing their healthcare needs, including medication management and coordinating appointments, might benefit from care coordination.
5. People with mental health or substance abuse issues that require multiple providers, programs, or services could benefit from care coordination to ensure comprehensive and integrated care.
6. Individuals with complex social needs, such as homelessness or food insecurity, may require care coordination to connect them with the appropriate resources and support services.
7. Caregivers of patients with complex medical needs may also benefit from care coordination to help them navigate the healthcare system and access the necessary support for their loved ones.

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What is care coordination referral form?

Care coordination referral form is a document used to request coordination of care services for a patient.

Who is required to file care coordination referral form?

Healthcare providers, social workers, case managers, or other professionals involved in a patient's care may be required to file care coordination referral form.

How to fill out care coordination referral form?

Care coordination referral form can be filled out by providing patient information, desired services, contact information, and any relevant medical history.

What is the purpose of care coordination referral form?

The purpose of care coordination referral form is to ensure that a patient receives appropriate and timely care by coordinating services between different healthcare providers.

What information must be reported on care coordination referral form?

Information such as patient demographics, medical history, current medications, insurance information, and reason for referral must be reported on care coordination referral form.