LifeLens Psychological & Counseling Services Coordination of Care with Primary Care Physician

LifeLens Psychological & Counseling Services Coordination of Care with Primary Care Physician
PATIENT INFORMATION:
(first)
(middle)
(last)
DOB
Primary Care Physician (all patients are asked to complete this section)
Physician Name
Street Address
City
Zip
Office Number
Fax Number
If Patient is a minor: Name of Parent / Guardian
Parent / Guardian Signature

Clear
Date

MonthDay Year
Date
Adult Patient Signature

Clear
Date

MonthDay Year
Date
Patients with Commercial Insurance Coverage
I consent to communication between lifeLens and my PCP (diagnosis and treatment)
(initial)
I decline to communication between lifeLens and my PCP (diagnosis and treatment)
(initial)
Patients with Medicaid Insurance Coverage
The Primary Care Physician assumes the role of health coordinator for each assigned patient. LifeLens has a contractual obligation to follow Medicaid insurance guidelines and is required to provide information of mental health services to the patient’s PCP. LifeLens is authorized to do so without a patient’s explicit consent.

LifeLens accepts the following Medicaid Plans: Aetna Better Health, Blue Cross Complete, HAP Empowered Health Plan, McLaren Health Plan, Meridian Complete, Priority Health Choice, United Health Care Community Plan.
LifeLens Psychological & Counseling Services
Should be Empty:

Patients with Commercial Insurance Coverage