with a chronic health condition, such as asthma, COPD, diabetes, heart disease, With the flu season upon us, I’d like to take the opportunity to remind …
CASE MANAGEMENT REFERRAL FORM
|Member Name: |Date of Birth: |
|Member : |Authorization if |
| |applicable: |
|Referral Type ie doctor office, self-referral, workplace wellness: |
|Primary Diagnosis: |
|Case Management Criteria 18-65 y/o |
|Diabetes |
|A1C average blood sugar higher than 90 or Date/result: |
|____________ |
|Fasting/non-fasting glucose |
| |
|Hyperlipidemia |
|LDL Bad cholesterol higher than 160 Date/result: |
|____________ |
|
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|Hypertension |
|Blood pressure higher than 140/90 Date/result: |
|____________ |
| |
|Complex Case Management |
|Complex medical conditions not age-specific |
| |
|Additional Disease Specific Criteria |
|Please check all that apply |
|Diabetes Past |
|heart surgery/procedure |
| |
|Hyperlipidemia High cholesterol Thyroid disease |
|
|
|Hypertension High blood pressure Tobacco use |
| |
|Obesity |
|Other: ______________________ |
|Additional Information: |
| |
| |
| |
| |
|Referred By: |
|Date: |
P5154-0805
