Remote Care Monitoring Request Form
Email requests to: passportcm@evolenthealth.com
Referral Date:
Primary Care Provider (PCP) Name:
Office Contact Name:
PCP Office Phone Number:
Member Demographics:
Member Name:
Date of Birth:
Email:
Passport Member ID:
Phone Number:
Diagnosis: __ Asthma __ COPD __ Diabetes __ Heart Failure
In addition to a diagnosis of Asthma, COPD, Diabetes, or Heart Failure, please mark which of the following
criteria the patient meets: (Member will be enrolled into Care Management along with Remote Care
Monitoring)
Asthma
__ Rescue and Maintenance Inhalers
__ Daily Nebulizer Use
__ Red Risk Score for Readmissions
__ 1 or More Dose of Steroids or Antibiotics in the
Past 6 Months
__ Asthma Diagnosis plus Hypertension Diagnosis
__ Asthma Diagnosis plus two or more medications
__ Asthma Diagnosis plus a Body Mass Index greater
than or equal to 30
BMI:
COPD
__ Home Oxygen Use
__ Daily Nebulizer Use
__ Red Risk Score for Readmissions
__ COPD Diagnosis plus Hypertension Diagnosis
__ COPD Diagnosis plus two or more medications
__ COPD Diagnosis plus a Body Mass Index greater
than or equal to 30
BMI:
