PATIENT ENGAGEMENT
REFERRAL FORM
Date of Referral
/
Month
/
Day
Year
Date
Person Submitting Request
*
First Name
Last Name
Submitter's Email
*
example@example.com
Submitter's Phone
Please enter a valid phone number.
Health Plan
Please Select
Anthem
Aetna
Cigna
Oscar
Imperial
MMP
Medicaid
Clover
Bright
Member's Name
First Name
Last Name
DOB
-
Month
-
Day
Year
Date
Member's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Spoken Language:
Primary Care Physician:
Date of Last office visit
-
Month
-
Day
Year
Date
Care Giver (if applicable)
Member's Phone Number
Please enter a valid phone number.
Visit with Community Health Advocate
Office has attempted contact with patient at least 3 times (include dates below). Patient needs to establish care via scheduling of appointment.
*At a minimum, Outreach has to be over 3 week period.
Attempt Date 1
-
Month
-
Day
Year
Date
Attempt Date 2
-
Month
-
Day
Year
Date
Attempt Date 3
-
Month
-
Day
Year
Date
Basic Needs Assessment
Telephonic or face to face visit with CommunityHealth Advocate (CHA), to assess barrier to care
Insurance/Benefit/Agent information-navigation
Basic education to patient regarding insurance inquiries. Possible referral to independent insurance sales agent
Community Resources
Transportation
Food Pantry
Financial
Quality Related Referrals
Scheduling Appointments
Medication Adherence
Request to Terminate Member
Visit with Community Health Advocate
Office has attempted contact with patient at least 3 times(include dates below). Patient needs to establish care via scheduling of appointment.
*At a minimum, Outreach has to be over 3 week period.
Attempt Date 1
-
Month
-
Day
Year
Date
Attempt Date 2
-
Month
-
Day
Year
Date
Attempt Date 3
-
Month
-
Day
Year
Date
Was a Certified termination sent?
Please Select
Yes
No
Letter Sent Date
-
Month
-
Day
Year
Date
Comments
Submit
Should be Empty: