Packaging Referral Form
Patient Name
*
First Name
Last Name
Patient Date of Birth (Month/Date/Year)
*
Patient Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Patient's Caretaker's Name or Care Facility
*
First Name
Last Name
Caretaker or Home Health Nurse's Phone Number
*
Please enter a valid phone number.
Home Health Agency Name
*
Patient's Sync Date
*
Pharmacy Location
*
Please Select
Chancy Drugs Adel
Chancy Drugs Hahira
Chancy Drugs Valdosta
Chancy Drugs North Valdosta
Chancy Drugs Moultrie
Chancy Drugs Lake Park
Patient's Primary Care Physician and Specialist list
*
Has the patient recently been discharged from a hospital or skilled nursing facility?
*
Please Select
Yes
No
If yes, what hospital or skilled nursing facility was the patient discharged from
*
Does the patient receive medication from any other pharmacy? This includes mailorder pharmacy
*
Please Select
Yes
No
If yes, What is the name and phone number of the pharmacy?
Will the patient pick their medications up or have them delivered?
*
Please Select
Pickup
Delivery
Patient's preference of day/time for us to call
*
Does the patient prefer phone calls or text message communication?
*
Please Select
Text
Call
Is there a preferred time of the month to have medications packaged?
Does the patient have vision or physical impairments that would hinder them from see the writing on the packs or opening the packaged medications?
Other Important Info (This would be any information that could be helpful for the Health Coach to know prior to reaching out to the patient).
*
Employee Name
*
First Name
Last Name
Pharmacist that has reviewed Patient Referral Form
*
Has the employee given the patient or caregiver the Chancy Drugs Packaging Pharmacy phone number and name of their health coach? Have you shown the patient or caregiver a sample of the packaged medication?
*
Please Select
Yes
No
Has the employee scanned in a copy of the patient's current Medicare (Red, White, and Blue) card and prescription coverage into Pioneer?
*
Please Select
Yes
No
Does the patient have Humana Insurance?
Please Select
Yes
No
If they do have Humana, do they understand they will incur a $25 monthly packaging fee?
Please Select
Yes
No
If this is an emergency, has someone contacted the Packaging pharmacy?
*
Please Select
Yes
No
N/A
If yes, who did you speak with in the Packaging pharmacy?
Please verify that you are human
*
Submit
Should be Empty: