0990HealthPromotionAppendix D

APPENDIX E

PHYSICIAN REVIEW FORM

REQUEST FOR PHYSICIAN REVIEW OF ASSESSMENT RESULTS AND ACTION PLAN FOR

INDEPENDENT LIVING AND MOBILITY STUDY (ILAMS)

To assure timely response to your patient’s needs, please respond by fax. It is important that you let us know that you received the Assessment Results and Action Plan, as well as to let us know if you have any concerns with the recommendations in the Action Plan. Thank you.

1^st Fax Date: ___________ # of Pages __________

2^nd Fax Date: ___________ # of Pages __________

To: ____________________________________ From: ___________________________________

Phone # ____________ Fax # _____________ Phone # ______________ Fax # _____________

Office Contact: _________________________

Your patient has authorized us to talk with you. Attached is the completed and signed HIPAA authorization to do so. This fax pertains to the ILAMS Assessment Results and Action Plan for:

Participant Name: Date of Birth:

Explanation of the attached ILAMS Assessment Results and Action Plan:

Your patient (named above) is a participant in the Independent Living and Mobility Study (ILAMS), a national Fall Prevention Demonstration Project, sponsored by the Department of Health and Human Services. Please see the attached Summary of Assessment Results and Action Plan. The patient was assessed at telephonically on {DATE} and at home on {DATE}.

PHYSICIAN RESPONSE to the findings of the ILAMS Assessment and Action Plan:

Please check all that apply, Then sign and date below

I RECEIVED THE ASSESSMENT RESULTS AND ACTION PLAN.

I HAVE THE FOLLOWING CONCERNS WITH THE ACTION PLAN:

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

I WOULD LIKE A COPY OF THE COMPLETE ILAMS ASSESSMENT SENT TO ME FOR INCLUSION IN THIS

PATIENT’S MEDICAL RECORD.

Physician Signature: __________________________________________ Date: __________________

The information contained in this facsimile transmission may be privileged and confidential and exempt from disclosure under applicable law. It is intended only for the use of the individual or entity named above. If you are not the intended recipient, or the employee or agent responsible to deliver it to the intended recipient, you are hereby notified that any dissemination, distribution or copying of this communication is strictly prohibited. if you have received this communication in error, please notify the sender immediately by telephone to arrange for return of the material to us. Thank you.

PLEASE FAX THIS COMPLETED FORM TO XXX-XXX-XXXX. Thank you.

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