Community Health Network Program Referral - Department Of Health printable pdf download

Community Health Network Program Referral - Department Of Health

Community Health Network Program Referral

Patient Information

Name

Gender c Male

c Female

Address

Birth Date

Program Preference:

c Morning

c Afternoon

c Evening

c Weekend

Best Phone to call:

Best time to call:

Currently enrolled in WISEWOMAN?

c Yes

c No

Special Accommodations?

Language

c Spanish

c Other (Please specify)_______________ c Physical or other special needs: _________________________

Primary Insurance:

c BCBS of RI

c United Healthcare

c Neighborhood Health Plan

c Tufts

c Medicare

Medicaid (check one):

c Rite Care

c ConnectCare

c Rhody Health

c None

c Other ________________________________

Healthcare Provider Information

Provider Name

Date

Agency / Practice

Phone

Fax

Send feedback to: c Same as above or

Name:

Phone

Fax

Patient Health Concern (Check all that apply)

c Arthritis

c Hypertension

If one of the below is checked, a Physician, NP, or PA signature is

c Asthma

c Pain

required:

c Cancer Survivor

c Youth with Special Needs

c COPD

c Nutrition Counseling

c Weight Management

c Other chronic condition:

c Fall-risk

c Diabetes

c Heart Disease

___________________________

c Pre-Diabetes

c Tobacco Use

Specific Program Request:

c Patient enrolled in onsite program, CHN Patient Navigator contact not needed. Program Name:____________________________________

Healthcare Provider Signature:

Healthcare Provider Notes:

• Please have the person being referred sign the authorization to disclose information to Community Health Network Programs.

• Keep a copy for your records.

• Provide the person referred with the Community Health Network Program materials.

• Send this form to Cindy Ariza or Catherine Cabral through secure fax (401-222-4418).

• Call Cindy Ariza (401-222-7636) or Catherine Cabral (401-222-7623) if you have any questions.

• The patient progress reports will be emailed or faxed to the number provided on this form.

Department of Health use only:

Date entered

Entered by

2/2015

Community Health Network Program Referral - Department Of Health

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