933142 03/2020
Patient and Referral InformationDate:
Last:First: MI:
Cigna ID:
State:
Patient Medical Information (optional)
Is the patient receiving counseling? Yes No
Is the patient currently taking antidepressant medication? Yes No
If yes, did you give patient samples? Yes No
Psychotropic Medication: Dosage: Date started:
Does the patient have any co-morbid medical conditions (e.g., diabetes)? Yes No
Cigna Behavioral Health Care Service is available
to assist in treatment planning and support for
our customers at the number listed.
The following patient has current symptoms of depression and should be evaluated for the Medicare
Advantage Depression Disease Management Program.
To refer a patient to the Medicare Advantage Depression Disease Management Program, simply complete
the patient information below. If time permits, please provide additional information in the medical
information section. Referrals can be submitted by mail or fax. Program staff are available by phone if you
would like additional information about this program.
The Medicare Advantage Depression Disease Management Program is designed for patients with a
depressive disorder. The program provides coaching and support by care management staff to help
improve your patient's adherence to treatment for depression.
Alcohol abuse/dependence
Anxiety disorder
Depression
Social phobia
Panic disorder
Bipolar disorder
Schizophrenia
Substance abuse/dependence
Phobias
Post-traumatic stress disorder
Obsessive-compulsive disorder
Other:
Does the patient have any co-occurring behavioral health conditions? Please check all that apply:
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INT_20_85388_C
Thank you for your referral to the Medicare Advantage Depression Disease Management Program!
If “Yes,” please list:
Has the patient ever been hospitalized for depression? Yes No
If “Yes,” discharge Date:
Psychotropic Medication: Dosage: Date started:
Psychotropic Medication: Dosage: Date started:
Diagnosis: Code:Date of diagnosis:
Is this patient aware that s/he is being referred to the Medicare Advantage Depression Disease
Management Program?
Yes No
Comments:
Physician name: Physician phone:
Referred by: Phone:
Gender:Date of Birth:
Health Care Provider Referral:
Medicare Advantage Depression Disease Management Program
500 Great Circle Drive, Nashville, TN 37228
Tel 866.780.8546 Fax 866.949.4846
Male
Female
