PCP to Behavioral Health Provider Communication Form

The PCP to Behavioral Health Provider Communication Form was created by the Independence Blue Cross Clinical Quality Committees, which include network physicians, to give physicians the opportunity to communicate vital information about patients to behavioral health providers when referring patients.

When you refer HMO patients to behavioral health providers, the patients are often sent to a particular site rather than to a particular provider. Therefore, the information that accompanies them may be less than complete. The PCP to Behavioral Health Provider Communication Form can help decrease the incidence of patients arriving for a referred service without a full picture of past treatments and methodologies. In addition, the form can aid providers in discussions with patients about treatments, especially as many members can self-refer.

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

Physicians must secure consent to forward personal information. Independence recommends that the completed form be given to the member to take to the behavioral health provider. 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.