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Date of Referral (MM/YYYY)
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Referred By
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Member's Name
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Member DOB
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PCP
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Email
Type Of Referral:
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Routine (will contact in 3-5 business days)
Urgent (will contact in 1-2 business days)
Emergent (will contact same business day)
If Emergent, State Reason
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Reason for Referral: select your reason(s) for referral
Behavioral Health Issue
Crisis (includes suicidal thoughts, threatening behavior)
Substance Abuse
Counseling
Other (please enter note below)
Social Work Issue
End of life concerns
Alzheimer's/Dementia
Financial
Elder Care Planning
Transportation
Abuse/Neglect
Other (please enter note below)
Hospitalizion Issue
Readmission within 30 days of last hospitalization
Frequent ER visits
Complicated or prolonged stay admission
Other (please enter note below)
Existing Service Concerns
Home Health Concerns
DME Concerns
Transportation
Other (please enter note below)
Existing Service Concerns
Non-Adherent With Medications
Non-Adherent with physician treatment plan
Medical Concerns regarding Acute and Chronic Disease Process (select all that apply)
Acute MI
COPD
Heart Disease
Pneumonia
Blood Thinner
CVA
Heart Failure
Post Surgical
Asthma
Depression
High Blood Pressure
Atrial Fib
Diabetes
Kidney Disease
Cancer
Falls
Neuro Issues
Other
Notes
Provider's Name
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