Coordination of Behavioral Health Care

Primary care providers and behavioral health specialists should use Priority Health's 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 COC 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