Best Practice Network Pcp Medical Record Update Form
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1
2BlueCare
SM
TennCareSelect
1 Cameron Hill Circle
Chattanooga, TN 373402
Best Practice Network PCP Medical Record Update
Type of Service
Consulting Provider Information Name:
Phone No. __________________________________________
F Behavioral Health
F Dental
F Specialist
F Health Department
Address: ____________________________________________
Fax No.: ____________________________________________
Patient Name: _____________________________________
Enrollee ID No.: ____________________________________
Patient Care Information
Date(s) of Visit(s): _______________________________________________________________________________________
Primary Diagnosis or ICD-10: ______________________________________________________________________________
Secondary Diagnosis or ICD-10: ____________________________________________________________________________
Diagnostic (including lab, imaging, etc.) and therapeutic services provided: ___________________________________________
_____________________________________________________________________________________________________
Is the primary (referral) condition resolved? F Yes F No (If no, comment on treatment plan)
_____________________________________________________________________________________________
Follow-up Care Date:
F This Office F PCP F Another Practitioner:
Recommendations/Comments: (Attach additional pages if necessary): _____________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
EPSDT Components
Please indicate if any of the following were performed
Mail or fax to Primary Care Practitioner at:
F Comprehensive Health and Developmental
F Immunizations
[please check any given]
History
(Please Print)
F HepB
F Comprehensive Unclothed Physical Exam
F DTaP
F Health Education
Name: _____________________________
F HIB
F Vision Screening
F IPV
Address: ____________________________
F Hearing Screening
F PCV
F Dental Screening and Referral
___________________________________
F MMR
F Laboratory Tests [
___________________________________
please indicate lab test(s) conducted]
F VZV
F Hematocrit
F HepA
Fax No.: ____________________________
F Blood Lead Level
F Other
Reviewed by PCP (Initial) _______________
F TB
F Other
(please indicate)
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Parent category: Business