IHH Care Coordination Referral Form

Care Coordination Referral Form

Care Coordination Referral Form
Provider Information
Date

MonthDayYear
Date
Physician Name
Specialty
Office Contact Person
Phone Number
Format: (000) 000-0000.
Fax Number
Please enter a valid phone number.Format: (000) 000-0000.
Patient Demographic Information
Patient Name

First NameLast Name
DOB

MonthDayYear
Date
Gender
Primary Contact Name
Primary Contact Phone
Format: (000) 000-0000.
Phone Number Type
Relationship to Patient

Other
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Languages Spoken
Needs Interpreter?
Insurance Information

Other
Member ID
PCP Name (if different from referring provider)
Referral Reasons
Diagnosis or clinical presentation of: (if known or suspected)

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
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