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Get Combined MCE Behavioral Health Provider/Primary Care Provider Communication Form 2012-2024

Combined MCE Behavioral Health Provider/Primary Care Provider Communication Form Health Plan Boston Medical Center HealthNet Plan Network Health Fallon Community Health Plan Neighborhood Health Plan PCC Plan HNE The member below is currently receiving services and has consented to share the following information between his/her PCP and BH provider. In an effort to increase communication and promote care coordination between providers we ask that you review and/or complete the following health information* Member name DOB Member ID A signed copy of the release of information ROI must be attached to this form* Indicate date of expiration of ROI Section A completed by BH Provider 1. The patient is being treated for the following behavioral health problem s and/or diagnoses list all diagnoses list all OTC medications with dosage and frequency as applicable Prescriber 3. The patient has the following BH MH/SA problem s if applicable applicable 4. Please describe any special concerns i*e* include abnormal lab results Primary Care Provider Behavioral Health Clinician Provider Name/Site Name Address Phone Fax Date this form completed To make a referral to Care Management please call the members plan at Boston Medical Center HealthNet Plan 866 444-5155 Network Health 888 257-1986 Fallon Community Health Plan 888 421-8861 Updated 9/20/2012. In an effort to increase communication and promote care coordination between providers we ask that you review and/or complete the following health information* Member name DOB Member ID A signed copy of the release of information ROI must be attached to this form* Indicate date of expiration of ROI Section A completed by BH Provider 1. The patient is being treated for the following behavioral health problem s and/or diagnoses list all diagnoses list all OTC medications with dosage and frequency as applicable Prescriber 3. The patient is being treated for the following behavioral health problem s and/or diagnoses list all diagnoses list all OTC medications with dosage and frequency as applicable Prescriber 3. The patient has the following BH MH/SA problem s if applicable applicable 4. Please describe any special concerns i*e* include abnormal lab results Primary Care Provider Behavioral Health Clinician Provider Name/Site Name Address Phone Fax Date this form completed To make a referral to Care Management please call the members plan at Boston Medical Center HealthNet Plan 866 444-5155 Network Health 888 257-1986 Fallon Community Health Plan 888 421-8861 Updated 9/20/2012. In an effort to increase communication and promote care coordination between providers we ask that you review and/or complete the following health information* Member name DOB Member ID A signed copy of the release of information ROI must be attached to this form* Indicate date of expiration of ROI Section A completed by BH Provider 1. The patient is being treated for the following behavioral health problem s and/or diagnoses list all diagnoses list all OTC medications with dosage and frequency as applicable Prescriber 3. The patient has the following BH MH/SA problem s if applicable applicable 4. Please describe any special concerns i*e* include abnormal lab results Primary Care Provider Behavioral Health Clinician Provider Name/Site Name Address Phone Fax Date this form completed To make a referral to Care Management please call the members plan at Boston Medical Center HealthNet Plan 866 444-5155 Network Health 888 257-1986 Fallon Community Health Plan 888 421-8861 Updated 9/20/2012. .

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