Physicians Plus provides Case Management services for members who 1) have complex medical or behavioral health conditions, 2) have high risk psychosocial concerns, 3) require disease management education, and 4) for whom case management assistance would likely reduce the member’s chance of adverse health outcomes.
To request Case Management for a Physicians Plus member, please complete the form below and fax to (608) 327-0322.
To: Physicians Plus Case Management / Fax: (608) 327-0322 / Date: / / .From: / Fax: / Phone:
Member Name: / DOB: / Member ID #:
Referral source (i.e. doctor, NP, PA, self-referral, spouse/caregiver, other):
Primary diagnosis:
History of present illness, chronic conditions, recent hospitalizations:
Reason for referral:
Additional questions:
· Is the member or primary caregiver aware that a Case Management referral has been initiated? Yes No
· Does the member need assistance managing his or her treatment plan, or coordinating services related to health or diagnosis? Yes [please explain] ______No
· Please indicate if the member is currently receiving any of the following:
Home health Radiation therapy Chemotherapy SNF Infusion Inpatient Rehab
Please include a recent H&P, clinical notes, and lab values as appropriate.
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This message is intended for the use of the individual or organization to which it is addressed, may contain confidential information, and is exempt from disclosure under applicable law. If the reader of this message is not the intended recipient, or an employee of the agent responsible for delivery of the message to the intended recipient, any dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please notify us immediately by telephone and return the original message to us at the address noted below. Thank you for your cooperation.
2650 Novation Parkway ▪ Madison, Wisconsin 53713 ▪ (608) 282-8900
P+5154-1507