TeleiCare Provider Referral Form

TeleiCare Provider Referral Form
- Referring Provider Full Name
  
  First NameLast Name
- Practice/Clinic Name
- NPI Number
- 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
  example@example.com
- Patient Full Name
  
  First NameLast Name
- Date of Birth
  
  MonthDayYear
  Date
- Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Email Address
  example@example.com
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Insurance Provider
- Member ID
- Group Number
- Subscriber Name (if different)
- Subscriber DOB
- Relationship to Patient (self, spouse, child, other)
- Which services is being requested?
  
  RPMCCMBoth
- Is the patient currently enrolled in Remote Patient Monitoring or Chronic Care Management with another provider?
  
  YesNoUnknown
- Does the patient have two or more chronic conditions expected to last 12 months?
  
  YesNoUnknown
- Diagnosis/Conditions
  
  HypertensionDiabetesHeart DiseaseCOPDChronic Kidney DiseaseObesityDepressionOther
- Reason for Referral/Additional Clinical Notes
- Has the patient been informed of this referral?
  
  YesNo
- 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
Should be Empty: