Pcp To Behavioral Health Communication Form
Download a blank fillable Pcp To Behavioral Health Communication Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Pcp To Behavioral Health Communication Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1PCP to Behavioral Health Provider Communication Form
ATTENTION Dr: _________________. The patient listed below is currently receiving behavioral health services and has
consented to share the following information with their PCP. In an effort to increase communication and promote care
coordination between providers, we ask that you review the behavioral health information in Section A. Please complete the
medical information in Section B.
Patient name: _____________________________________ DOB: ____/____/____ Insurance ID#: _______________________
SECTION A (to be completed by behavioral health provider)
SECTION B (to be completed by PCP)
1. Attached is a signed copy of the release of information:
1. Attached is a copy of the notes from the patient’s last visit
Y
N
Y
N
2. The patient is being treated for the following behavioral
2. The patient is being treated for the following medical
health problem(s): (list all diagnoses)
problem(s): (list all diagnoses)
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
3. The patient is taking the following prescribed psychotropic
3. The patient is taking the following prescribed
medication(s): (list all medications and dosage)
medication(s): (list all medications and dosage)
__________________________ ______________________
__________________________ ______________________
__________________________ ______________________
__________________________ ______________________
__________________________ ______________________
__________________________ ______________________
__________________________ ______________________
__________________________ ______________________
4. The patient has the following substance abuse issue(s): (if
4. The patient has the following substance abuse issue(s): (if
applicable)
applicable)
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
5. Please describe any special concerns:
5. Please describe any special concerns:
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
Psychopharmacologist, if applicable:____________________
PCP Name Completing Form:
_________________________________________________
BH clinician name: _________________________________
Address: __________________________________________
Address: __________________________________________
State: ____________ ZIP: _________________
State: ____________ ZIP: _________________
Phone:____________________________________________
Phone:____________________________________________
Fax: ______________________________________________
Fax: ______________________________________________
BH Clinician Signature: _______________________________
PCP Signature: _____________________________________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Life