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Primary care providers and behavioral health specialists should use Priority Health's Coordination of Care (COC) form (407KB
PDF) to communicate about:
Using the COC form
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:
Section 5: Response Requested Designate the type of response you would like from the practitioner. For example:
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
02/10/10
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