Care Management Request Form - Independent Physicians Network

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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:

This form and its contents are or may be legally privileged and confidential information intended solely for the reciepient. You are hereby notified that any dissemination, distribution, copy of other use of this message or its contents is strictly prohibited. If you have received this form in error, please notify us immediately by telephone at 1-414-771-6177 and return the original message to us at 6767 West Greenfield Avenue, Suite 300, Milwaukee WI 53217 via the United States Postal Service and destroy all electronic and hard copies of this communication, including any attachments