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INT_19_75016_C 05032019 928895
Patient name: Patient date of birth:
Phone number: Provider:
Alternate contact (PR/family member/caregiver): Phone number:
Personal representative (PR) authorization form is on le
Requestor category: PCP Optum Urgent care ED Complex/specialty case management
Other Priority: Routine Urgent
Requestor name:
Requestor return phone number: Requestor return fax number:
Follow up with requestor after services have been provided
Community/living environment resources
Caregiver/respite Meals Transportation Dementia programs Loss/bereavement
Elder law resources Aordable housing Group home/assisted living facilities
ALTCS consideration as monthly income is conrmed as less than $2,313 (2019 limit)
Homeless; note how to contact Other (specify)
Focused assessment and care management intervention related to:
Frequent ED/acute care utilization Access to care/navigation of health care system
Social determinates of health, suspected determinate:)
Medication management (possible pharmacy review indicated)
Health literacy concern Fragile adult living alone
Unstable living environment Dysfunctional family dynamic impacting health
Domestic violence (not a replacement for mandatory reporting obligation of referral source)
Behavioral health/substance use disorder Other (specify)
Health information/education support:
Diabetes CHF COPD Certied diabetes education class (new DM dx or A1C < 8.5)
Financial assistance resources
Medication cost assistance Health insurance premium assistance Utility assistance
Patient has given consent for Cigna care management outreach, including nursing and/or social work
Yes (must be checked in order for the referral to be processed)
Situation driving request:
Patient background:
Existing barriers:
Services requested (Select all that apply. Patient must give consent for outreach before services can be provided.
Please include supporting documentation with the referral.)