Care Coordination Form (Ccf) printable pdf download

Care Coordination Form (CCF)

The CCF is a vetted tool for documented information sharing between a home visiting agency and the primary care medical home regarding a patient. The

needed parent/guardian consents that meet both the Health Insurance Portability and Accountability Act (HIPAA) and the Family Educational Rights and

Privacy Act (FERPA) requirements are built into this form. This consent form authorizes the referring agency to share pertinent information with the

medical home and provides consent for the medical home to share relevant patient information with the referring home visiting agency.

Section 1. Family Contact Information

Patient Name: __________________________________________ AKA_______________________ Patient is (check one) ☐child

☐mother

Parent/Guardian Name (if patient is under 18): ___________________________________________AKA________________________________

Street Address: __________________________________________________________________________________________

City: ___________________________________ State: __________ Zip: ______________ County: _____________________

Patient Date of Birth: _____/_____/_____

Patient Gender: M F

Race: _________________________________________

Type of Insurance Coverage:

Medicaid

Private Insurance Medical card # _____________________________________

Name of Previous Healthcare Provider: __________________________________________________

Primary Language: ___________________________ Home Phone: _____/_____-_______ Other Phone: _____/_____-_______

Alternate or Emergency Contact Person: _____________________________________________ Phone: _____/_____-_______

Section 2. Reason(s) for Contact

Reason(s) for contact (Please check all that apply):

☐Family/Patient has been assigned a home visitor (see Section 3. Referral Source Contact Information)

☐ Suspected medical condition or previous medical diagnosis (e.g., spina bifida, Down syndrome): ____________________________________

☐ Concern based on objective screening using:

☐ 4P’s Plus

☐ Relationship Assessment Tool

☐ Edinburgh Assessment

☐ ASQ-3 Assessment

☐ ASQ-SE Assessment

☐Other, specify__________________________________________________

Other Area(s) of concern (please check all that apply):

__Motor/Physical __Cognitive __Social/Emotional __Speech __Language/Communication __Behavior __Vision

__Hearing __Adaptive/Self-help skills __Maternal Mental Health __Relationship assessment __Substance Use

Comments

_______________________________________________________________________________________________________________

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_______________________________________________________________________________________________________________

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☐ Referral made to ____________________________________(name of referral source) on _______________________(date referral made)

☐ Request for patient medical information (please specify the type of information)_______________________________________________

__________________________________________________________________________________________________________________

Family is aware of reason(s) for contacting the Primary Care Provider

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Care Coordination Form (Ccf)