Download medisun care management referral

MEDISUN CARE MANAGEMENT REFERRAL
Client Name:
Date:
Address:
PCP:
Phone: __________________________________________________ DOB: ____________
Diagnoses __________________________________________________________________
Network:
Insurance:
AIP
BAMC
MediSunONE
BPHO Insurance ID# _____________________________
HeartSmart
PLEASE CHECK THE FOLLOWING REASON(S) FOR REFERRAL
1.
Multiple related hospital admissions or Emergency Treat & Release visits.
2.
Catastrophic or chronic illness/complications requiring major changes in lifestyle, living
arrangements or caregiver roles.
3.
Suspected emotional, social or financial problems complicating health status.
4.
Suspected knowledge deficit about disease process, medications or management.
5.
Non-adherence with medication, diet, medical treatment or appointments.
6.
Cognitive/behavioral issues contributing to impaired self care/ decision making.
7.
Enroll in the following disease management program(s)
Diabetes
Healthy Heart
Glucometer instruction
Pre-Diabetes
Hypertension
Pulmonary Rehab
8.
Individual instruction
Insulin/Byetta injections
Dietary ___________________(specify diet order)
Please provide information regarding patient’s current clinical conditions and needs:
Referral Source:
Phone/pager:
FAX Form to: 623-974-7496 or Contact MediSun Care Management at 623-974-7403.
Banner Health MediSun
13632 N 99th Ave
Sun City, Arizona 85351
623-974-7430 1-800-446-8331 www. Medisun.com
TTY for the hearing-impaired 1 800-367-8939 or 866-331-2188