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Request Number:
Member Name: Member ID#
Member Address Physician Name
Member Phone:  -   -  Physican Phone:  -   - 
Member Birth Date:    
Diagnosis:   Diabetes  COPD  CHF  CAD  Other
Special Instructions:
 
Reason for Request: Inpatient DIAGNOSIS
 Admitted to Hospital  Inpatient Discharge Follow Up
Date       Date      
Hospital Name  Frequent ER Admissions
Hospital Phone  -   -   Frequent OBS Inpatient Stay
 Admitted to LTAC/SNF/LTC
Date       DIAGNOSIS
Facility Name
Facility Phone  -   - 
 
REASON FOR REQUEST: OUTPATIENT
 Behavioral Health Coordination  Home Care Coordination  Dialysis  DME Coordination
 Education & Adherence Monitoring for:
 Non-Compliance of:
 Outpatient Procedure Follow Up
Comments:
 
REASON FOR REQUEST: MISCELLANEOUS & SOCIAL NEEDS
 Care Coordination with Multiple Specialists Community Resources
Specialist Type Social/Family Support Assessment
Specialist Name
Specialist Phone  -   - 
Comments:

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