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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.

Last modified: 4/14/2011
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