Fillable Coordination of Care Checklist

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Coordination of Care Checklist

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Client Name: ___________________________________
Coordination of Care Checklist
Client Name: _____________________________________ DOB: ____________________________
Date of Admission to Services: ______________________ Clinician: _________________________
Is there a Primary Care Physician? ____Yes ____No Is there another Behavioral Health (BH) Clinician? ____Yes ____No
PCP Name: __________________________________ Other BH Clinician’s Name/License: _____________________________
Phone Number/Fax Number: ___________________ Phone Number/Fax Number: ____________________________________
Release of Information Signed? ___Yes ___No ___Refused Release of Information Signed? ___Yes ___No ___ Refused
If Refused, Reason: ________________________________ If Refused, Reason: _________________________________
Dates of Communication with PCP Dates of Communication with Other BH Clinician
PCP Communication Comments (include any problems with the
communication process)
Other BH Clinician Communication Comments (include any
problems with the communication process)
rev. 2/11/11
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Coordination of Care Checklist

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Completed 4 January 2021

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