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Behavioral Health Practitioner Communication Form


This form aids physicians in communicating vital information about patients to behavioral health practitioners when referring them. The form details relevant health information such as medication use (to avoid contraindications), past and present medical conditions, allergies, relevant lab results, and contact information for the referring physician. It can also aid in discussions about treatments and provide a full picture of past treatments and methodologies with patients.

Although the form was created for Independence Blue Cross physicians, it can be easily adapted for use in other practices.


Independence Blue Cross

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Independence Blue Cross

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  • Original Summary: 01/2011
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Last updated: February 02, 2011.