Patient Condition Form

Name*
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Are you already enrolled in Captive Heath's RN Care Management?*
Condition*
What documents for Diabetes are you submitting now?*

Provider Visit (every 6 months)Diabetic Exam (1x annual)hA1C Test Result (every 6 months)Cholesterol Panel (1x annual)Creatine (1x annual)Urine Microalbumin (1x annual)
What documents for High Blood Pressure are you submitting now?*

Provider Visit (every 6 months)Cholesterol Panel (1x annual)Creatine (1x annual)Potassium (1x annually) — Required only if on a diuretic medication
What documents for High Cholesterol are you submitting now?*

Provider Visit (every 6 months)Cholesterol Panel (1x annual)
If you are already enrolled in Captive Heath's RN Care Management, you do not need to resubmit information here.

Instead, contact Care Manager Kim Barns at kbarns@captivehealth.org or 319-531-7472 for assistance or to submit any information.
Upload your indicated documents*

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