PCP to Behavioral Health Provider Communication Form

The PCP to Behavioral Health Provider Communication Form was created by the AmeriHealth Clinical Quality Committees, made up of network physicians, to give you the opportunity to communicate vital information about patients to the behavioral health practitioners to which you refer them.

When you refer HMO patients to behavioral health practitioners, the patients are often sent to a particular site rather than to a particular practitioner. Therefore, the information that accompanies them may not be complete. The PCP to Behavioral Health Provider Communication Form can help decrease the incidence of patients arriving for a referred behavioral health service without a full picture of past treatments and methodologies. In addition, the form can aid practitioners in discussions with patients about behavioral health treatments, especially since many members can self-refer.

This form enables you to communicate relevant health information to the behavioral health practitioner, including medication use (to avoid contraindications), past and present medical conditions, allergies, relevant lab results, and your contact information.

Physicians must secure consent to forward personal information. AmeriHealth recommends that the completed form be given to the member to take to the behavioral health practitioner. For HMO patients, the form can accompany the referral.

We encourage you to make copies of this form for use in your practice. Our hope is that this form will help you to facilitate comprehensive care to meet all the health-related needs of our members and your patients.

Download the PCP to Behavioral Health Provider Communication Form.