Collaboration of Care form
This form is for PCPs and Therapists to touch base on shared cases. For a response, please have patient fill out a HIPPA release on our website under "handouts and forms."
Patient name
Observations
How would you like to be contacted (patient can fill out a release on our website)
Fax me at my secure fax
Email me at my secure email
Call me
I will call your office to arrange a time to speak (734 707 1052)
No response needed, just wanted to share observations
Your Name
First Name
Last Name
Email
example@example.com
Phone Number (if that's how you want to be reached)
-
Area Code
Phone Number
Fax number (if that's how you want to be reached)
-
Area Code
Phone Number
Submit
Should be Empty: