Primary Care Provider (PCP) Information & Care Coordination

Client Name:

First NameLast Name
DOB:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Medicaid ID or Commercial Insurance ID:
MCO ID:
Primary Care Provider (PCP) Information & Care Coordination
Why are we asking for this information?
Your physical health and mental health are connected. Your primary care provider (PCP) may have important information that can help your behavioral health provider better understand your overall needs and provide coordinated care. Your insurance company or Managed Care Organization (MCO) may also require behavioral health providers to make reasonable efforts to coordinate care with your PCP when appropriate.
Who is your Primary Care Provider?
PCP/Doctor's Name:
Practice/Clinic Name:
Phone Number:
Format: (000) 000-0000.
Fax Number (if known):
Format: (000) 000-0000.
Address (if known):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PCP Status Options
Information Released To: Phoenix Preferred Care, Inc.
480 E. University Dr. Suite 7A, Somerset, KY 42503
Phone: 606.451.9379 Fax: 606.451.8149
Information to be released: Physical Health/Medical Summary, Immunization Records
Purpose of Release: To aid in treatment planning and care coordination
I authorize the release of the information identified above for treatment, care coordination, and/or insurance/MCO requirements, as applicable.

I understand that:
- I may revoke this authorization in writing at any time, except to the extent action has already been taken based on it.
- I may request a copy of this authorization.
- Information disclosed may be subject to redisclosure as permitted by law.
- Signing this authorization does not authorize release of unrelated medical records.
Client/Legal Representative Printed Name:

First NameLast Name
Signature:
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Relationship to Client (if applicable):
Should be Empty:

Primary Care Provider (PCP) Information & Care Coordination

Who is your Primary Care Provider?