Get the free Care Coordination Referral Form - Peoples Health

Care Coordination Referral Form (For Peoples Health Choices Select and Peoples Health Secure Choice Plans) Provider: Please type or print and fax a completed form to the Medical Management department

How to fill out care coordination referral form

How to fill out a care coordination referral form:

1. Start by gathering all necessary information: Before filling out the care coordination referral form, make sure you have all the required information handy. This includes the patient's personal details, medical history, current medications, and contact information.
2. Provide accurate patient details: Begin by filling in the patient's full name, date of birth, gender, and any other relevant identification information. This ensures that the referral form is correctly associated with the intended patient.
3. Specify the reason for the referral: Clearly state the reason for the referral in the designated section of the form. Include any relevant medical conditions, symptoms, or concerns that require care coordination.
4. Include relevant medical history: Provide a thorough medical history for the patient, detailing any previous diagnoses, treatments, surgeries, or hospitalizations. This information helps the care coordination team understand the patient's health background.
5. List current medications: Include a comprehensive list of all medications the patient is currently taking, including prescription drugs, over-the-counter medications, vitamins, and supplements. This allows for proper medication management and prevents potential drug interactions.
6. Document other healthcare providers involved: If the patient is already seeing other healthcare professionals, note their names, specialties, and contact information. This helps the care coordination team communicate and collaborate effectively with other providers.
7. Specify desired outcomes: Clearly state the desired outcomes or goals of the referral. This could involve seeking specialized care, accessing certain medical services, or receiving additional support for the patient's condition.

Who needs a care coordination referral form:

1. Patients with complex medical needs: Care coordination referral forms are beneficial for patients with multiple chronic conditions or complex medical needs. Coordinating care between various healthcare providers ensures comprehensive and holistic treatment.
2. Individuals transitioning between healthcare settings: Those who are moving from one healthcare setting to another, such as a hospital to a rehabilitation facility or home care, may require care coordination services. The referral form facilitates the smooth transition and continuity of care.
3. Patients requiring specialized care: If a patient requires specialized care from a specific healthcare professional or facility, a care coordination referral form is necessary to ensure effective communication and collaboration between all parties involved.

Remember, the care coordination referral form is a vital tool for ensuring seamless communication, collaboration, and comprehensive care for patients with complex medical needs or those transitioning between healthcare settings.

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What is care coordination referral form?

The care coordination referral form is a document used to refer patients to care coordination programs or services.

Who is required to file care coordination referral form?

Healthcare providers, such as physicians, hospitals, and clinics, are typically required to file the care coordination referral form.

How to fill out care coordination referral form?

To fill out the care coordination referral form, you will need to provide the patient's personal information, medical history, and reason for referral. The specific instructions for filling out the form may vary depending on the organization or program.

What is the purpose of care coordination referral form?

The purpose of the care coordination referral form is to facilitate communication and collaboration between healthcare providers and care coordinators, ensuring that patients receive comprehensive and coordinated care.

What information must be reported on care coordination referral form?

The information typically reported on a care coordination referral form includes the patient's name, contact information, relevant medical history, reason for referral, and any specific care coordination needs.