Behavioral Health / Medical Care Coordination Referral Form

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Tele# 719 867-2184
Fax: 719 867-2144
Tele#248 697-0500 Fax#248 697-0904
Behavioral Health / Medical Care Coordination Referral Form
Referral Date: ____________ Referrer’s Name__________________ Tele# __________________
Member Name: ________________________________ Kaiser ID #: ________________________
Address (only if different than Kaiser/ VO in system): ___________________________________
Member Contact (or Representative) Tele #____________________________________________
Primary Care Physician (per the member): ____________________________________________
Reason for Referral: ______________________________________________________________
 yes
 no
Is member aware that we may be calling?
Behavioral Health Status: __________________________________________________________
Medical Status: ___________________________________________________________________
Behavioral Health to Medical
Untreated medical condition and/or non compliance with medical treatments impacting the member’s
behavioral health recovery an/or potential for worsening of condition
 Uncontrolled Diabetes
 Congested Heart Failure along with Chronic Obstructive Pulmonary Disease
 Terminal or end stage cancer
 Eating Disorder that may result in medical inpatient treatment.
 Chronic pain out of control impacting the member’s mental health status.
 Polypharmacy with no obvious physician management coordination (more than one prescriber).
 Other (specify):
Medical Health to Behavioral:
 Risk Rating of 3 identified during Utilization Review
 Untreated psychiatric condition with risk to self or others.
 Depression or other behavioral health issue(s) affecting compliance with medical treatment and/or
impacting medical health.
 Polypharmacy with no obvious physician management coordination (more than one prescriber).
 Controlled Substance case identified by Kaiser Permanente Polypharmacy Initiative via the
Pharmacy Department and/or Resource Stewardship Care Management process for behavioral
health intervention.
 Autism Referral Request
 Other (specify):
 yes  no
Attachments:
Explain: ________________________________________________
Signature: __________________________________ Title: ___________________________
Call ValueOptions at 248 697-0701 to alert that fax sent.
 yes  no
Return Call / Disposition Requested:
To Whom? __________________________________ Tele# for Contact: ________________
719 867-2144
248 697-0904
KAISER PERMANENTE FAX NUMBER:
VALUEOPTIONS FAX NUMBER:

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