RPM Patient Referral Form

Patient RPM Referral Form

Refer a patient for RPM enrollment upon discharge / office visit:
Voice Record Your referral
Patient Name*

First NameLast Name
Patient DOB*

MonthDayYear
Date
Patient MRN*
MRN
Patient's Phone Number **
Please enter a valid phone number.
Your Name *

First NameLast Name
Your Email
example@example.com
Enter IMEI Number - Assign a device
15 digits
Patient's Medical& Care Management Challenges

1. Difficulty managing multiple medications and understanding prescriptions2. Inability to recognize early warning signs of heart failure exacerbation3. Lack of follow-up home support with primary care or cardiologists4. Limited access to Telehealth services5. Increased risk of hospital readmission due to poor symptom managementOther
Patient's Social & Economic Challenges (SDOH Considerations)

1. Financial Barriers2.Housing Instability3. Food Insecurity4. Transportation Issues5. Health Literacy & Language BarriersOther
Patient's Emotional & Behavioral Health Challenges

1. Depression, anxiety, or feeling of isolation post-discharge2.Lack fo caregiver support for assistance with daily activities and adherence to care plans3. Cognitive impairment leading to confusion about medications, diet, or symptom monitoringOther
Patient's Lifestyle & Behavioral Challenges

1. Difficulty maintaining necessary lfiestyle changes, such as diet modification and fluid restrictionsadherence to prescribed physical activity recommendations due to fatigue or mobility limitations3. Continued smoking, alcohol use, or other behaviors that worsen heart failure symptomsOther
Optum Hospitalist Name
Add New Hospitalist Name
Optum Hospitalist Phone Number
Please enter a valid phone number.
Name of the Optum Cardiologist
Discharge Hospital
Add New Discharge Hospital Name
Discharge Date
Schedule the next appointment by

MonthDayYear
Next appointment
Choose program(s)

Chronic Care Management (CCM) - No devicesRemote Patient Monitoring (RPM) - With DevicesContinuous Glucose Monitoring (CGM) - Diabetic patients with patchesOther
Choose RPM Devices

Blood PressureWeight ScalesPulse OximeterGlucometerThermometerPeak Flow MeterSmart WatchOther
Cuff Size
Patient Primary Point of Contact's Name

First NameLast Name
Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Fax Patient Discharge Summary (845)398-4224

https://www.lucidact.com/optumtristate
Please Rate your referral experience
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Patient RPM Referral Form

Fax Patient Discharge Summary (845)398-4224