Follow Up Coordination

Follow Up Coordination Form

Patient Information

Patient Name

Patient ID

Date Of Birth

MM slash DD slash YYYY

Appointment Date

MM slash DD slash YYYY

Provider Information

Practice Name

Physician Name

Hidden

NPI

Patient Report

Patient Report / Notes

Drop files here or

Accepted file types: jpg, jpeg, gif, png, pdf, Max. file size: 8 MB.

Follow Up Requested

No follow up necessary

Repeat colonoscopy

Consult

Refer to specialist

Procedure

Diagnostic Imaging

Labs

Other

Repeat Colonoscopy Date(Required)

MM slash DD slash YYYY

When should patient come back for a consult?(Required)

Please enter an approx date, Assist Health will call to schedule appointment.

MM slash DD slash YYYY

Follow Up Process

Assist Health will confirm with the patient and submit a follow up consult scheduling request. Do not put patient in schedule until you receive the request from us.

Specialty(Required)

Specialist Practice or Name(Required)

Procedure

Colonoscopy

Upper Endoscopy

Colonoscopy and Upper Endoscopy

Hemorrhoid Banding

Capsule Endoscopy

Colorectal Surgery

Other

Other Procedure(Required)

Diagnostic Imaging Studies Ordered(Required)

List all studies needed

Diagnostic Imaging Order

Including the order will greatly expedite scheduling

Max. file size: 8 MB.

Lab Tests Ordered(Required)

List all lab tests needed

Lab Order

Including the order will greatly expedite scheduling

Max. file size: 8 MB.

Describe follow up needed

Additional Notes

Additional notes or instructions for Assist Health

Be detailed so that the care coordination team can coordinate succesfully

Name

This field is for validation purposes and should be left unchanged.

Follow Up Coordination