Important Note: You are not permitted to use or disclose protected health information about individuals who you are not
currently treating or are not enrolled to your practice. This applies to protected health information accessible in any online tool,
sent in any medium including mail, email, fax or other electronic transmission.
IAPEC-0174-15 February 2016
Coordination of care and treatment summary
In accordance with acceptable medical practice, Amerigroup Iowa, Inc. requires network behavioral
health care providers, primary care providers and other appropriate medical providers involved in a
member’s treatment to coordinate care. Please complete this form and send it to the appropriate
provider(s) treating this member after obtaining written patient consent, in compliance with all
applicable state and/or federal regulations.
Member name:
Date of birth:
A. Your information
Practice name:
B. Other provider information
C. Member clinical information
1. I am treating the member for the following diagnosis(es):
2. The member is taking the following prescribed medication(s) that I have prescribed:
3. (For behavioral health providers only) The member is engaged in the following psychotherapeutic intervention(s):
Frequency of intervention(s):
4. Coordination of care issues/other significant information affecting medical or behavioral health care:
Fax or mail form to [list other provider(s)]:
Date mailed or faxed:
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