Coordination of behavioral health care
Primary care providers and behavioral health specialists should use the Priority Health Coordination of Care (COC) form (407KB PDF) to communicate about:
- Requests for consultations
- Medication management or therapy
- Obtaining dates of behavioral health sessions regarding optimal contacts
- Providing information to a patient's provider
Using the Coordination of Care form
- To request information: complete Sections 1-5.
- To provide information: complete Sections 1, 4 and 6.
- Mail the original and keep a copy for your records.
Section 1: Patient information
Complete all fields.
Section 2: Reason for referral
Identify the reasons why you are referring the patient to another provider. Check all boxes that apply.
Section 3: Indicators
Identify what conditions have been affecting the patient's emotional and physical health. Check all boxes that apply.
Section 4: Service requested
Select the treatment/service the practitioner can provide:
- One-time consultation
- Consultation and comanagement of the patient
- Manage the patient's treatment
- Manage medications
- None - communication only (when the form is being used solely for communication)
Section 5: Response requested
Designate the type of response you would like from the practitioner. For example:
- Practitioner's findings or recommendations based on the consultation (all documentation should be attached)
- Dates of the behavioral health sessions
- Written notes and a phone call to further coordinate care
- Referral communication (indication that patient has contacted or scheduled an appointment with the practitioner)
Section 6: Response
(For responding provider use only)
- Complete if you receive the COC form.
- Record your findings or treatment recommendations.
- If dates of behavioral health sessions are requested, provide the dates of two sessions that occurred after the original requested date.
- If you need more room, indicate you are continuing your statement either on the back of the form or on an attachment.
- Be sure to sign and date the form.
For Office Use Only:
Sent/Referred to: Print the name of the receiving practitioner and the referral date
Sent/Referred by: Use when identifying the date and office personnel sending the form.
