MFC Provider Assistance Program Notification Form

Enrollee Information

Enrollee Name*

First Name

Last Name

Enrollee Date of Birth*

Enrollee MFC-DC ID Number*

Enrollee Phone Number*

Enrollee Preferred Language*

Contact Method and Follow-up Preference*

Phone Text Mail No Preference

Is the enrollee aware of this referral (optional)

Yes No

Enrollee Parent/Guardian Name (if applicable)

Provider Information

Provider Name*

First Name

Last Name

Provider ID Number*

Role in the enrollee's care team*

Primary care provider (PCP) Specialist

Office Contact Name*

Office Contact's Phone Number*

Office Contact'sFax Number

Office Contact's Email Address*

Best Time to Call*

Follow-up preference*

Fax Call Email

Reason for provider assistance program referral

Assist/Educate with transportation to medical appointment Assist/Educate with location of PCP Educate about MCO processes Need contact from Special Needs Coord. (please specify reason below) Provide information about community-based services Assist provider with scheduling appointment Follow-up on repeated missed appointments Follow-up on repeated ER usage/educate enrollee to use PCP for care

Other:

Provide information about community-based services for:

List dates of the missed appointments

Results of outreach

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Campaign Source

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Campaign Medium

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Campaign Term

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Campaign Content

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Campaign Name

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GCLID (Google Click Identifier)

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