Request for Deletion of Patient from Case Management List

Request for Deletion of Patient from Case Management List

PCP: / Patient Name:
PCP Phone: / AllianceID #:
Date of Request: / Patient Phone #:

Reason for Request

Requests for non-medically necessary care and or medications/narcotics

Unsatisfactory doctor/patient relationship

Failure to keep scheduled appointmentsAbusive or disruptive behavior

Non-compliance with Case managementOther (describe below)

1)Describe circumstances in detail and/or attach documentation supporting request:

2)Describe efforts you have made to address this issue with the patient and/or attach documentation:

3)Member has been notified by letter on:

4)Does this delete request include any Family Members: Yes No

Reminder: The member will remain linked to your practice until the effective date indicated verbally or in writing from The Alliance. Until that date, you are required to ensure access to care either by providing it yourself or referring the member out to another provider via the Referral Authorization Form (RAF). In addition, you are responsible for authorizing any specialty care services that the member may require until the effective date of the delete.

Primary Diagnosis: Secondary Diagnosis:

Prognosis:

Active medical issues:

Signature of PCP requesting deletion:Date:

ALLIANCE STAFF ONLY

ApproveDenyEffective DateSignature

Medical Director

Comments:

Creating Healthcare Solutions

CCAH 1011 (10/2008)

Date:

Dear ,

I have asked Central California Alliance for Health (Alliance) for approval to stop seeing you as a patient. I have done this for the following reason(s):

Requests for care or medicine that is not medically necessary

Poor doctor-patient relationship

Not keeping appointments

Disruptive behavior

Not following plan of care

Other (describe)

I will continue to be your Primary Care Provider (PCP) until the Alliance makes a decision on my request. During this time, I will still be responsible for your medical care.

You will get a call or a letter from the Alliance letting you know their decision. If the Alliance approves my request, I will no longer be your doctor. The Alliance will let you know when the approval will be effective. The Alliance will help you to pick another Primary Care Provider (PCP).

Please feel free to contact me at if you have any questions about this letter.

Sincerely,

Form: CCAH 1011 (7/05)

Fecha: ______

Estimado/a ,

He pedido a la Alianza de la California Central (Alianza) aprobación para dejar de verle como paciente. He hecho esto por la(s) razón(es) siguiente(s):

Hace pedidos para cuidado o medicina que no es medicamente necesario

Relación pobre entre doctor y paciente

Conducta disruptiva

Está perdiendo sus citas

No sigue con el plan de cuidado

Otro:

Continuaré siendo su Proveedor de Cuidados Primarios (PCP) hasta que la Alianza haga una decisión sobre mi pedido. Durante este tiempo, todavía seré responsable de su cuidado médico.

Usted recibirá una llamada o una carta de la Alianza que indicará su decisión. Si la Alianza acepta mi pedido, yo dejaré de ser su doctor. La Alianza le hará saber cuando la aprobación será efectiva. La Alianza le ayudará a escoger a otro Proveedor de Cuidados Primarios (PCP).

Por favor siéntase libre de contactarme al si usted tiene cualquier pregunta acerca de esta carta.

Sinceramente,

Form: CCAH MS-16-1 PEV (Rev: 7/05)