Health Plans, Inc. Disease State Management Request Member name: ________________________________________________ Member ID #: _________________________________________________ Current PCP: _________________________________________________ Member Health Status: __________________________________________ _____________________________________________________________ _____________________________________________________________ By my signature below, I agree to provide health care services to this patient as his/her primary care physician. I fully understand my obligations as described by the Milliman & Robertson, Inc. guidelines provided to me in the Health First Health Plans, Inc. Provider Manual. Member Authorization: ___________________________
Member Signature date _________________________________ Print Member Name
Physician Specialist Authorization: ______________________________
Specialist Signature date ____________________________________ Print Specialist Name
Submitted by: ____________________________________ Signature date ____________________________________ (title) For Health First Health Plans use only: Approved by: _________________________________ Signature date _________________________________ (title)
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