TCM Form

Approximately one in five Medicare beneficiaries in the United States are readmitted to the hospital within 30 days of discharge; up to 76 percent of these readmissions may be preventable. A common reason for readmissions is the absence of timely follow-up appointments with primary care providers to assist patients with their new diagnoses, medications and treatments.

Transitional Care Management (TCM) addresses the hand-off period between the inpatient and community setting. After a hospitalization or other inpatient facility stay (e.g., in a skilled nursing facility), the patient may be dealing with a medical crisis, new diagnosis, or change in medication therapy. Family physicians often manage their patients’ transitional care.

Note:

  1. Please fill the following TCM form.
  2. Fax Demographics & Clinical Record to: 214-390-1212

Transitional Care Management Form

Fields marked with an * are required

Transitional Care Management Form
A. Facility Information :

Upcoming Specialist Appointments

B. Patient Information :
Schedule Type *
This Patient is *
File Upload (Facesheet, Clinical documents etc)
Maximum upload size: 10MB

Referral Form

Fields marked with an * are required

Referral Form
A. Referring Provider/Facility:
B. Patient Information:
Is Patient *
C. Appointment Requirements
Urgency of Appointment *
Purpose of Referral *
File Upload (pertinent clinical information)
Maximum upload size: 516MB