Western Health Advantage

WESTERN HEALTH ADVANTAGE

DISEASE MANAGEMENT REFERRAL FORM

Date: 2/4/12

Recipient Information

Sender Information

To:

Health Promotion and Disease Management Department (HPDM)

Contact Name:

Company:

WHA

Phone:

Attention:

Email address:

Fax:

(916) 568-0278

Phone:

(888) 563-2250 ext. 2267

Patient Information

First Name:

MI:

Last Name:

Phone:

WHA ID #:

Sponsor Information

First Name:

Last Name:

Check if member is the sponsor

Street Address:

City, State & Zip:

Physician Information

Physician Name:

PCP Specialist

Office Phone:

Other Phone:

Disease Management Programs (Please check all that apply)

Diabetes Program*

Coronary Artery Disease (CAD) Program*

Asthma Program

Comments/Brief History(optional):

Enter text that you see in the image:

IMPORTANTE: ¿Puede leer este documento? Si no, nosotros le podemos ayudar a leerlo. Además, usted puede recibir el documento escrito en español. Para obtener ayuda gratuita, llame ahora mismo a Western Health Advantage al (888) 563-2250, de lunes a viernes de 8am a 5pm.

Proprietary & Confidential
Important Warning: This message is intended for the use of the person or entity to which it is addressed and may contain information that is privileged and confidential, the disclosure of which is governed by applicable law. 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 disclosure, copying or distribution of this information is Strictly Prohibited. If you have received this message by error, please notify the sender immediately to arrange for return or destruction. Unauthorized re-disclosure for failure to maintain confidentiality could subject you to penalties described in federal and state law.

12/09

HPDM-019