Care Coordination Form (Ccf) (Page 2 of 2) in pdf

Section 3. Referral Source Contact Information

Submission Date: _____/_____/_____

Name of Referral Source: ________________________________Name of Referral Source Agency: ____________________________________

Address: _____________________________________________City: _______________________________State: ______ Zip Code: ________

Referral Source Contact Phone: _____/_____-_______ Referral Source E-mail: _________________________________________

Referral Source Agency Office Phone: _____/_____-_______ Office Fax: _____/_____-_______

Additional Contact person at Referral Source Agency: ________________________________________________________

Section 4: Primary Care Provider Contact Information

Name of Patient’s Primary Care Provider: ___________________________________________________________________

Street Address: _______________________________________________________________________________________

City: ______________________________________ State: _____________

Zip Code: ___________________________

Office Phone: _____/_____-_______ Office Fax: _____/_____-_______ E-mail: ___________________________________

Contact Person at Primary Care Provider Office: ____________________________________________________________

Section 5: Authorization to Release Information

a. Information Sharing with Primary Care Provider. The purpose of this disclosure is to share information concerning

___________________________ (print name of patient) with the patient’s primary care provider. I, __________________________________(print

name of patient or name of parent/guardian if the patient is under 18), give my permission for the referral source contact,

____________________________________ (print name of referral source contact), to share pertinent information about

_________________________________________ (print name of patient), regarding specified reason(s) for contact under Section 2. Reason(s)

for Contact of this form, with the primary care provider_________________(print name of primary care provider). I understand that I may withdraw

this consent by written request to the referral source contact, except to the extent it has already been acted upon.

b. Information Sharing with Referral Source. The purpose of this disclosure is to release information from the primary care provider

about____________________(print name of patient) including name, date of birth, relevant referrals made, and relevant medical information as

requested by the referral source under Section 2. Reason(s) for Contact, to the referral source contact. I understand that I may withdraw this

consent by written request to my primary health care provider, except to the extent it has already been acted upon.

This consent allows the Referral Source to share pertinent information with the assigned primary care provider (doctor) and treating

doctors within the group, for care coordination. Care coordination allows the Referral Source to receive relevant medical information (as

specified under Section 2. Reason(s) for Contact of this form) concerning the named patient from the assigned primary care provider

(doctor) and treating doctors within the group

I certify that this Authorization to Release Information has been given freely and voluntarily. Information collected hereunder may not be re-

disclosed unless the person who consented to this disclosure specifically consents to such re-disclosure and or the re-disclosure is allowed by law.

I understand I have a right to inspect and copy the information to be disclosed.

Patient or Parent/Legal Guardian Signature (if patient is under 18)*_____________________________________Date:_______/_______/_______

*Consent is effective for a period of 12 months from the date of patient or parent/legal guardian signature on this release.

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Care Coordination Form (Ccf) Page 2