Care Management Request Form - Independent Physicians Network

Care Management/Care Coordination Follow Up

Member Name *

Member ID# *

Member Address

Apt, suite, etc.

Country

City

State

Zip code

Member Phone *

Member Birth Date *

Physician Name *

Physician Phone *

Diagnosis Other

Special Instructions

Reason for Request: INPATIENT

Admitted to Hospital

Yes

Hospital Admission Date

Hospital Name

Hospital Phone

Hospital Diagnosis

Frequent ER Admission

Frequent OBS/Inpatient Stay

Inpatient Discharge Follow Up

Discharge Date

Admitted to LTAC/SNF?LTC

Yes

Facility Name

Facility Phone

Facility Admission Date

Reason for Request: MISCELLANEOUS & SOCIAL NEEDS

Community Resources

Social/Family Support

Care Coordination with Multiple Specialists

Specialist Type

Specialist Name

Specialist Phone

Comments:

Confidential:

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