PCCN - Care Coordination Referral

PCCN - Care Coordination Referral

PCCN - Care Coordination

This referral form is intended to be used by healthcare professionals who have patients that need assistance from PCCN's Integrated Care Coordination services. To qualify for PCCN's care coordination service, patient's must be aligned to a PCCN pariticipating provider under one of PCCN's insurance partners.

Name of Person Completing Form*

Referral Date*

Practice Name or Group Name*

Name of Contact at Practice*

Practice Contact Email

Is this a SDoH referral that was collected using a validated screener?*

Select

Patient Race*

Select

Patient Ethnicity*

Select

Screening Date*

Please select all SDoH needs:*

Select

Is patient requesting assistance with their SDoH Needs?*

Select

Are these needs urgent?*

Select

Reason for Referral (Please be descriptive)*

What support does the family need? (i.e. needs assistance coordinating specialty care, non-compliance, mental health services, disease management, education support, primary care coordination, community resources, etc.)

Patient Information

Patient's Name*

Date of Birth*

Sex*

Male

Female

Insurance Plan*

If patient's insurance is not listed here, the patient is not eligible for PCCN Care Coordination.

Mercy Care (inc DDD/ALTCS/DCS)

United HealthCare Community Plan (inc DDD and ALTCS)

Health Choice AHCCCS

Cigna CAC - Open Access Plus

ACN Connected Care (Intel)

Insurance ID*

PCP Name*

If patient's PCP is not a participating Phoenix Children's Care Network PCP, patient is not eligible for PCCN Care Coordination. Check PCP here: https://phoenixchildrens.org/pccn/find-a-pccn-doctor

PCP Phone Number

Phone

Is LAR aware of referral?*

Yes

Legal Parent / Guardian (LAR)

Name:*

Preferred Communication Method*

Select

Phone Number:

Phone

Email Address

Relationship to Patient*

Send me a copy of my responses

Privacy Notice|Report Abuse