Common Contracts

Mesa County Physicians IPA Care Coordination Agreement Referral Form

Care Coordination Agreement • October 24th, 2017

• Contract Type
  Care Coordination Agreement
• Filed
  October 24th, 2017

PROVIDER REFERRAL REQUEST FORM REFERRING TO Specialty: Phone: Fax: Date: Practice Name & Address: Please Schedule (select all that apply): Urgent-- Referring physician called  Routine Appointment with Specific Physician listed:  First Available with any Physician Referring Provider’s Name: Phone: Fax: TYPE OFREFERRAL  Medical Consultation with treatment recommendations that primary care physician will continue to follow Procedural Consultation  Specialist to Specialist*–Secondary Referral*Send copy of this referral to patient’s Primary Care Physician. Co-management: Assume principal care for this condition  Other (designate)  Co-management: I prefer to share the care for this condition PATIENTINFORMATION Patient Full Legal Name: DOB If patient is under 18 years old – Parent Contact Name: Preferred Phone: Best time to call: Special Patient Considerations: Patient Insurance Information: Patient’s Primary Care Provider: Phone: Fax: GENERALINFORMATION Reason for Referral (Clin