2023 State Trooper Surgeons Medical Options Request

EXECUTIVE CARE INTAKE FORM

State Trooper Surgeons Medical Options Request
PLEASE PROVIDE THE INFORMATION REQUESTED BELOW AND CLICK SUBMIT WHEN COMPLETE.

A copy of the form will be automatically emailed to the email address you provide. Please keep this on hand to have available upon request when speaking with Emily Dixon, Executive Care Coordinator, at 518-462-7448 Ext. 140.
1) Patient Full Name*

First NameMiddle NameLast NameSuffix
2) Rank or Title Ex. BCI, Trooper, Spouse, Family Member
3) Troop*

ABCDEFGKLNYCT
4) Patient DOB:*
5) Patient Street Address:*
Patient City:*
Patient State/Zip:*
6) Phone Number*
7) Secondary Contact Person & Relationship to Patient:
Optional
8) Secondary Contact CELL Phone Number
9) Primary Contact E-mail Address:
10) How far are you willing to travel?*
Ex. 30 min or 50 miles
11) PATIENT CONSENT: The patient has given permission for the aforementioned Primary Contact Person to represent or speak on his/her behalf. Further, permission is provided for the State Trooper Surgeons Executive Care Coordinator to speak with medical providers and their staff for the purposes of developing medical options for the medical issue outlined below:*

Yes
12) Current Physician who is treating the medical issue: *
13) Current Physician Phone Number: *
14) Is your current physician willing to send a referral on your behalf if needed?*
15) Insurance Name:*
16) Insurance Number:*
17) Worker's Compensation Claim Number (if applicable):*
18) Brief Description of Medical Issue:*
19) Specific Request for Medical Assistance:*
20) EAP Referral*

YESNO
CANCER CARE, TRANSPLANTS & INFERTILITY:

Center of Excellence Enrollment
For the Empire Plan (NYSHIP), patients should determine if the care facility of choice is listed as a Center of Excellence for the following conditions:
- Cancer Care
- Transplants
- Infertility
Patients must call 1-877-769-7447 to enroll after selecteding a listed Center of Excellence.

The following are some of the benefits of enrollment when appropriate:
- Paid-in-full benefits including in and outpatient hospital services and physician care related to approved services.
- Travel, meal and lodging expense allowance when pre-authorized and enrolled in the Center of Excellence program.
- Other benenfits may apply. Understand more about this benefit at Empire Plan Centers of Excellence
MEDICAL RECORDS DISPOSITION:

Important: You will be required to either obtain and forward, or request your physician(s) to forward, all pertinent medical records and/or imaging to your newly selected provider prior to being seen. Please make arrangements to have your records sent upon request.
Please contact Emily Dixon, Executive Care Coordinator, State Trooper Surgeons, at 518-462-7448 Ext. 140 or at edixon@nystpba.org for assistance with this form. Once this form is submitted, we will contact you within 24 hours.
AUTHORIZATION: Submitting this form gives PBA Executive Care Staff the necessary authorization to accept only the medical information you have provided on this intake form, and to forward this information to necessary medical professionals to establish medical options for your care.
Should be Empty:

EXECUTIVE CARE INTAKE FORM

CANCER CARE, TRANSPLANTS & INFERTILITY: