Plan outreach form template 2026

1. Click ‘Get Form’ to open the plan outreach form template in the editor.
2. Begin by filling in the required fields at the top, including Member Name, Age, and Date of Birth. Ensure accuracy as this information is crucial for processing.
3. For members under 21, provide the Date of Last Screening and Gateway Health ID Number. Next, enter Parent/Guardian Name and their Relationship to the member.
4. Complete the PCP (Primary Care Provider) section by entering the PCP Name, Provider ID Number, and contact details. This ensures proper communication regarding member care.
5. In the referral section, indicate why the member is being referred by checking appropriate boxes and providing additional details where necessary. Include dates for screenings or missed appointments if applicable.
6. Finally, add any Additional Information that may assist in understanding the member's needs before submitting your completed form.

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