Accuhealth Tele POC

Patient Submission Form

Please provide as much information as possible.
Clinic Name Doctor Name*
Please enter the Clinic name
Your Email Address*
example@example.com
Patient Information
EMR ID
*Only for clinics with existing EMR integration
First Name*
Middle and Last Name*
Date of Birth*
mm/dd/yyyy
Insurance Number*
Preferred Language
Street *
City *
State*
Zip*
Phone*
3455558534
Diagnosis Code - Hypertension
Diagnosis Code - Diabetes
Diagnosis Code - Pulmonary
Diagnosis Code - Weight
Diagnosis Code - Sleep
Diagnosis Code - Other
Did you provide device(s) to patient at your clinic?

If yes, please provide the device type and the device IMEIs below
Device Type (if device is being deployed in clinic)
IMEI Number of 1st Device
Device Type (if device is being deployed in clinic)
IMEI Number of 2nd Device
Are you also referring this patient for Chronic Care Management (CCM) or Principal Care Management (PCM) services?
Chronic Care / Principal Care

NoYes
If yes, specify any additional chronic conditions that apply to this patient.
Example: E785, F419, N189, etc
If yes, specify any care plan notes that apply to this patient.
Please provide any details of the patients current care plan which will help our CCM team document the patient's care plan in the CCM portal.
You hereby confirm that you are authorized to refer this patient to Accuhealth Services
Signature*

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Patient Submission Form