TeleiCare Provider Referral Form

TeleiCare Provider Referral Form
Referring Provider Information
Referral Provider Full Name
Practice/Clinic Name
NPI Number
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number
Email Number
Patient Information
Patient Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Section
Insurance Provider
Member ID
Group Number
Subscribe Name (if different)
Subscriber DOB
Relationship to Patient (self, spouse, child, other)
Referral Type
Which services is being requested?
Is the patient currently enrolled in Remote Patient Monitoring or Chronic Care Management with another provider?
Does the patient have two or more chronic conditions expected to last 12 months?
Diagnosis/Conditions
Reason for Referral/Additional Clinical Notes
Referral Authorization
Has the patient been informed of this referral?
Upload Supporting Document: Discharge Summary, Medication List, Notes, Labs

Cancelof
I certify that the above patient information is accurate to the best of my knowledge. I am referring this patient for evaluation and potential enrollment in TeleiCare services (RPM and/or CCM). I confirm that the patient has been informed of this referral.

I understand that TeleiCare will verify eligibility and contact the patient directly.
Signature
Date

MonthDayYear
Date
FACILITY ID
Should be Empty:

TeleiCare Provider Referral Form

Referring Provider Information

Patient Information

Insurance Section

Referral Type

Referral Authorization