Follow the steps to complete the form confidently.

1. Press the ‘Get Form’ button to obtain the form and open it in your preferred online document editor.
2. In the first section, enter the date and fill in the member’s basic information, including their name, date of birth, insurance plan, and insurance ID number.
3. Proceed to Section A. Attach a signed copy of the information release form. Then, fill out the diagnosis details including AXIS I, AXIS II, and AXIS III.
4. List the current medication along with dosage and frequency.
5. Describe the current treatment modalities and expected duration, specifying the frequency of treatment.
6. Include details about the behavioral health clinician and, if applicable, the psychopharmacologist. Provide their address, phone number, and fax number.
7. In Section B, the Primary Care Provider (PCP) should make a note to contact the behavioral health provider by phone or fax to request a copy of the patient’s last physical report and the date of the last appointment.
8. Fill in the medical information, which may include medication and any medical concerns.
9. Finally, include the signature of the provider completing the communication form.
10. Once all sections are complete, save your changes, and you can opt to download, print, or share the form as needed.

Take the next step in enhancing communication between providers by filling out your forms online.