Case and Condition Management Physician Referral Form

Contact Information (* required fields)

*Name:

*ID number:

*Date of birth:

*Preferred contact telephone number:

Best time to reach member: AM PM

Pertinent Data

*Diagnosis:

*Current medications:

BP:

Height: ft. in.

Cholesterol:

Blood glucose:

Weight: lbs.

Triglycerides:

Requested Intervention

*Please check all that apply and specify in the space provided.
A case manager will contact your office to follow up on the requested interventions.

Medication adherence:

Educational support: (diagnosis/condition, treatment, resources, etc.)

Socioeconomic support: (medications, food, financial resources, etc.)

Wound care:

Home care services: (skilled nursing, PT, OT, ST, IV therapy)

Investigate benefits for medical equipment rental/purchase:

Condition management: (chronic condition or disease)

Routine maternity:

High-risk pregnancy:

Nutritional support: (information, counseling, weight management)

Compliance with treatment plan:

Community resource information: (other potential resources for members)

Other:

Additional Information

Please enter any additional information you may have:

Physician and Contact Information

*Physician name:

*Contact name:

*Contact telephone number:

*Contact email address:

*Date form completed:

To ensure your privacy, all information will be sent via a secure connection. Independence Blue Cross will not disclose any personal information to outside persons or entities unless we have written consent or unless authorized by law.

Please see our Notice of Privacy Practices for more information.