Health and Wellness Referral Form
Please note: All emails that contain PHI must be sent in an encrypted method using a DHCS approved solution. Rev: 01/2020
Member Information
Member Name:
Member CIN #:
Current Address:
City:
ZIP:
Current Phone: 2nd Phone :
Date of Birth: Age: Gender: Male Female Other
Parent/Caregiver/Guardian Name:
Language(s): Arabic Chinese English Farsi Korean Spanish Vietnamese Other:
Referral Reason: Select 1 only. Attach labs and/or progress notes from the past 30 days
Prediabetes (A1C: 5.7 to 6.5%)
Diabetes A1C %: _______________ Type 1 Type 2
Gestational Diabetes
ICD10 code(s): __________________________________________
Weight:
Date of Calculation: ____________________________________
Height (inches):___________ Weight (pounds): _________
BMI: _____________________ BMI %: ___________________
Other referral reason not listed (specify):
Asthma
Cholesterol
Chronic Kidney Disease (CKD)
Chronic Obstructive Pulmonary Disease (COPD)
Congestive Heart Failure (CHF)
Depression
Exercise/Fitness
Heart-Related Conditions
Hypertension (HTN)
Nutrition (Specify topic): ________________________
Tobacco Cessation
Known Co-Morbidities:
Barriers/Needs: Behavioral Health Cognitive Family/Caregiver Support Food Insecurity Hearing
Housing Insecurity Physical Vision Transportation Other (specify): _____________________
Instructions/Comments: _______________________________________________________________________________________
____________________________________________________________________________________________________________
REQUIRED PROVIDER INFORMATION
Provider Name:
Provider NPI #:
Provider Address:
City:
ZIP:
Provider Phone:
Provider Fax:
Office Contact:
Phone:
Provider Signature:
Date:
Office stamp
Please attach labs and/or progress notes from the past 30 days.
Fax: 1-714-338-3127; Email: healthpromotions@caloptima.org; Questions: 1-714-246-8895
Download the form: www.caloptima.org/healtheducation
