Get Primary Care Provider Behavioral Health Communication Form

Filling out the Primary Care Provider Behavioral Health Communication Form online is a crucial step in facilitating effective communication between behavioral health providers and primary care physicians. This guide provides comprehensive instructions to ensure users can accurately complete the form with ease.

Follow the steps to fill out the form correctly.

1. Click ‘Get Form’ button to obtain the form and open it in the online editor.
2. Begin by entering the member's health plan by specifying the name of the insurance coverage.
3. Input the date on which you are completing the form to ensure accurate record-keeping.
4. In the section marked for member details, fill in the member's name, date of birth, insurance plan, and insurance ID number.
5. Move to Section A and confirm if there is an attached signed copy of the release of information.
6. Document the diagnosis by filling in details under Axis I, Axis II, and Axis III as applicable.
7. List the current medications the member is taking including dosages and frequency.
8. Describe the current treatment plan and expected duration, including modalities and frequency of therapy.
9. Provide the behavioral health clinician's information, including their name, address, phone number, and fax number.
10. In Section B, write a note stating that the PCP should contact the above behavioral health provider via phone or fax.
11. Attach a copy of the patient's last physical examination and note the date of the last appointment.
12. Complete the medical information by including details on medications and any medical concerns.
13. Finally, the provider must sign the form to confirm that the communication form has been accurately completed.
14. After ensuring all fields are filled out correctly, save changes, and choose to download, print, or share the completed form as needed.

Complete the Primary Care Provider Behavioral Health Communication Form online today to enhance care coordination!