IHH Care Coordination Referral Form

Care Coordination Referral Form

Care Coordination Referral Form
Provider Information
Date

MonthDayYear
Date
Physician Name*
Specialty

AdultPediatricianFamily MedicineGeriatrician
Office Contact Person
Phone Number
Fax Number
Please enter a valid phone number.
Patient Demographic Information
Patient Name*

First NameLast Name
DOB*

MonthDayYear
Date
Gender

MaleFemaleTransgender
Primary Contact Name
Primary Contact Phone
Phone Number Type

HomeCellWork
Relationship to Patient

Self/PatientSpouseParentLegal GuardianSiblingFriendGrandparentFoster-parentDaughter/SonOther
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Languages Spoken
Needs Interpreter?

YesNo
Insurance Information*

HMSA PPOHMSA HMOHMSA QuestHMSA Akamai AdvantageUHAHMAAUnitedHealthcareAlohaCareOhanaMedicare - Humana PPOMedicare - Humana HMOMedicare - UnitedHealthcareOther
Member ID*
PCP Name (if different from referring provider)
Referral Reasons*

Medical: coordination of care (specialist and other providers)Behavioral health: coordination for evaluation, dx, referral to mental health provider.Geriatric/caregiver support: evaluation for referrals and services.Family/Social determinates: family counseling, SDOH (housing, transportation, food, state/fed programs)Annual Wellness Visit (AWV): coordination for AWV, screening, health education.Transition of care: ER visit, hospital or inpatient discharge.Developmental delay: referral to state agency (DOE, DDD) and other community resources.
Diagnosis or clinical presentation of: (if known or suspected)

Major Depressive Disorder (F32, F33)Mild cognitive impairment or Dementia (F03.A11, F03.B11)Sleep Disorders (G47.00, F13.20)Anxiety Disorders (F41.1, F41.9)Other
Additional Comments (Provider's Request or Recommendations). Field is limited to 25 words.

0/25
How has the patient's physician been consulted? IHH services cannot be provided to the patient unless physician has been consulted and approves the referral.*
Name of person referring other than physician (please include your credentials, if any):
Providers Signature*

Clear
NOTES: (1) Send follow-up reports if there are significant changes (2) For more information and detailed report, contact the IHH care coordinator.
Should be Empty:

Care Coordination Referral Form

Provider Information

Patient Demographic Information