Care Coordinator Data Form

Care Coordinator Data Form

Please provide your basic information and details about your medical history and therapy needs.
Patient Demographics
Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address (It is preferred we get this)
example@example.com
Local Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
ZIP CODE*
This will alert the provider assigned to this area
*Other Address (WE NEED THIS IF IT IS ATTACHED TO MEDICARE) *Will be on verification report

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Medicare Details
Medicare Number
Effective Date
The MEDICARE has been Verified
Secondary/Supplement Provider
Company
Policy Number
Effective Date
Medical History (MOST IMPORTANT!)

Please try to get ALL the history you can as this helps the Coding and continued reimbursement process.
Past Medical Conditions: (Sometimes you will have to probe a bit and ask questions)
Stroke, Heart Attack, AFIB, Cancer, Heart Disease, Arthritis, Osteoporosis, Diabetes, Edema....and more
Surgical History (I usually ask if they have ever had surgery?)
Joint Replacements/Repair, Heart Surgery, Broken Bones, Stomach/Bowel, ect.....
IF NOT LISTED ABOVE Check any that apply
Current Medications
Medications (Don't Need Exact Name and Dose---JUST WHY THEY TAKE THEM)
Example: Blood Thinner, Antidepressant, High Cholesterol, High Blood Pressure, Thyroid Medication, Diuretic, ECT..
Functional Status
Mobility Level
Home Environment
Living Situation
Home Accessibility Issues
Assistive Devices
Assistive Devices Used

Other
Pain Assessment
Do you currently have pain?
Pain Location(s)
Pain Severity (0 = No pain, 10 = Worst possible pain)

0

1

2

3

4

5

6

7

8

9

10

0 is No pain, 10 is Worst pain
Falls History
Have you fallen in the past 12 months?
Number of Falls
Describe Circumstances of Falls
Trip, Lost Balance, Passed Out, Got weak
Cognitive Status
Any memory or cognitive concerns?

Other
Therapy Goals
Please describe your therapy goals
Notes
Notes
Should be Empty:

Care Coordinator Data Form

Patient Demographics

Medicare Details

Secondary/Supplement Provider

Medical History (MOST IMPORTANT!)

Current Medications

Functional Status

Home Environment

Assistive Devices

Pain Assessment

Falls History

Cognitive Status

Therapy Goals

Notes