Counseling African Americans To Control Hypertension (Caatch) Study Page 2
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59. Current Insurance Status (Check all that apply)
____ Medicaid (Fee for service)
____ Medicaid Managed Care (check one):
____ABC
____Affinity
____Americhoice
____CarePlus
___ Center Care
____Community Choice
____Community Premier Plus
____Fidelis Care
____Health First
____Health Plus
____HIP
____MetroPlus
____Neighborhood Health Providers
____New York Presbyterian CHP
____Partners in Health
____United HC
____WellCare
____Managed Care Plan (Other ______________________________________________)
____ Medicare /Medicare Managed Care
____ Employer / Private Insurance
____ Other (Specify______________________________________________)
____ None
____ Insurance Not Noted
Visit History:
10.
Date of First Visit and/or Progress Note: (mm/dd/yy)
/
/
11.
Date of Most Recent Visit: (mm/dd/yy)
/
/
12.
Date of Most Recent Primary Care Visit: (mm/dd/yy)
/
/
13.
Visit Count in the past 12 months ________
(Visits with MD, PA, NP, CNM: Internal Medicine, Family Medicine, OB/GYN)
14.
Visit Count in the past 12 months / other specialty NOT Cardiologist, Endocrinologist: ___________
(Visits with MD, PA, NP: Surgery, Podiatry, Psychiatry, Psychology, Urology)
15.
Date of most recent Cardiology Visit ____/____/____
Date of most recent Endocrinology Visit ___/___/__
Study ID
Site #
Reviewer ID
G:CAATCHAssessmentsChart Review
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Parent category: Business