Referral Form - Pending auto reply email and sheet

Chronic Care Management, Remote Patient Monitoring, Nutrition Therapy, and Care Coordination

Patient Referral Form: For use by healthcare providers to refer patients to Greens Health CCM, RPM, Nutrition Therapy, and Care Coordination services.
Patient Information
Full Name:

First NameLast Name
Date of Birth (DOB):

MonthDayYear
Gender:
Phone Number

Area CodePhone Number
Email
example@example.com
Address:
Referring Provider Information
Provider Name:
Practice Name:
Specialty:
Provider Phone

Area CodePhone Number
Provider Email:
example@example.com
Fax Number:
Practice Address:
Reason for Referral (Check all that apply)

Chronic Care Management (CCM)Remote Patient Monitoring (RPM)Nutrition TherapyCare Coordination
Primary Diagnosis (ICD-10 Code): Please list two or more eligible chronic conditions, such as Diabetes, Hypertension, Chronic Kidney Disease, or Asthma, along with their corresponding ICD-10 codes.
Secondary Diagnoses (if Applicable)
Relevant Medical History/Conditions (e.g., diabetes, hypertension):
Patient Eligibility Criteria (Check all that apply)

Diagnosed with a chronic condition (e.g., diabetes, hypertension)Experiencing challenges with medication adherenceHigh A1C levels (>9%) or unmanaged diabetesRequires nutrition education or therapyFacing social determinants of health barriers (e.g., transportation, food insecurity)Requires ongoing care coordination and monitoring
Current Medications and Allergies
Medications:
Known Allergies:
Requested Services
Remote Monitoring Devices Needed (if applicable):

Glucose Monitor (BGM/CGM)Blood Pressure CuffWeight Scale
Preferred Communication Method:

PhoneEmailSMS/Text
Additional Notes or Special Instructions
Preferred Communication Method:

I confirm that the patient has been informed about the referral and consents to participation in Greens Health services.EmailSMS/Text
Consent and Authorization
Referring Provided Signature

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Date

MonthDayYear
Should be Empty:

Chronic Care Management, Remote Patient Monitoring, Nutrition Therapy, and Care Coordination