TCM Form

WE ARE MOVING: Effective June 01, 2022, we will be seeing patients at 3315 Colorado Blvd, Suite 101, Denton, TX 76210

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: 134.22MB