Dhec 3714 Form – Fill Out and Use This PDF

Best Chance Network

Case Management Intake Form

(Use this form to fax a referral to SC DHEC BCN PA Line 1-866-297-6814)

Last Name:

First Name:

MI:

Address:

City:

State:

Zip:

County:

SSN#:

Patient's Home Phone #:

Patient's Work Phone #:

Referral Source: BCN

Referring Facility:

Referred by:

Phone #:

(Person making referral)

Doctor's Name:

DOB:

Race:

Marital Status:

Emergency Contact: Name:

Relationship to Client:

Home Phone #:

Work Phone #:

Test Results: (Referral to Discipline, Orders)

Results

ICD 9 Code

Date

1.

Abnormal Breast Exam

796.4

2.

Mammogram-ACR Code 4 (Suspicious)

793.80

3.

Mammogram-ACR Code 5 (Highly Suggestive Malignancy)

793.89

4.

Breast Ultrasound-ACR Code 4 or 5, Solid Mass

611.72

5.

Fine Needle Cyst Aspiration-

a. Indeterminant

610.0

b. CIS

233.0

c. Malignant Cells

174.9

6.

Pap Smear-Atypical Glandular Cells of Undetermined Signiicance (AGUS)

795.00

7.

LSIL Pap Smear Low-Grade Squamous Intraepithelial Lesion

795.03

8.

Pap Smear-High Grade SIL (HGSIL)

795.04

9.

Pap Smear-Squamous Cells of Carcinoma/Adenocarcinoma

233.1

10.

Pap Smear-Atypical Squamous Cells of Undetermined Signiicance-can not

exclude High Grade SIL (ASC-H).

795.02

11.Positive HPV DNA Test. (only if Pap Smear result is Atypical Squamous

 Cells of Undetermined Signiicance(ASCUS) - do not refer if Pap result is

negative)

795.05

12. Pelvic Exam-Suspicious for Cervical Cancer

616.0

Comments:

Missed Follow-Up Appt.

Refused Referral

Unable to Contact

Late Referral for Incomplete Follow-up

Follow-up Referral: Follow-up Facility:

Phone #:

Purpose of Follow-up Referral:

Date of Appointment:

Medicaid Coverage Effective Date:

Would you like the social worker to contact you before seeing the client?

Yes

No

BCN Staff taking referral:

Date:

DHEC 3714 (10/2012)

SOUTH CAROLINA DEPARTMENT OF HEALTH AND ENVIRONMENTAL CONTROL

Instructions for Completing the

Best Chance Network

Case Management Intake Form

DHEC 3714

Purpose: This form is to be used as an intake form for the BCN staff in order to complete a referral for BCN case man- agement services. The case managers will use the form for identifying the reason for the referral and to supply support- ive and identifying information. The appropriate district/county staff will also use the form for entering the BCN client in the Novius system.

Item by Item Instructions: In the irst box complete the identifying data for the BCN client being referred for case management services.

In the second box complete the blank for the referring facility (physician’s ofice), enter the name of the person faxing in the referral and the phone number where you can be reached.

In the third box complete the remaining identifying information as requested.

Test Results: Circle the number by the appropriate diagnosis and then give the date the test was completed.

Comments: Give additional information that might help the case manager in providing services for the client. Mark the appropriate box(s) for the items listed.

Follow-up Referral: Write the name of the follow-up referral facility and phone number. Then complete the reason for the follow-up referral and the date of the appointment.

Medicaid Coverage Effective Date: Complete date that Medicaid is effective if known.

Mark the appropriate box, Yes or No, for request for social worker to contact the referring person prior to seeing the client.

Person Receiving Referral: The appropriate BCN staff receiving the referral needs to sign their name. All referrals must be signed by the staff who receives and processes the referral.

Date: Put the date that the referral was received and faxed to the social worker/case manager.

Ofice Mechanics and Filing: The original and three copies of this form are kept in different ofices.  The BCN staff member keeps a copy in a notebook in their ofice.  The Case Management program coordinator housed in Home Health keeps a copy in her ofice and the BCN Quality Management Coordinator keeps the original in the BCN ofice.  Appropri-

ate personnel will keep all three of these under lock with limited access. These forms will have a retention schedule of

one year and should be shredded at the end of that year. A copy of the referral also goes to the appropriate district social worker/case manager. This form should be iled and retained in the clinical record in accordance with standards of the

Comprehensive Health Record User’s Manual and Home Health guidelines.

DHEC - 3714 (10/2012)