Your full name
Phone number
Email
Patient's full name
Humana member ID
Date of birth
Phone number (optional)
Does this patient have a caregiver?
YesNo
Full name
Phone number
What is your patient's primary health goal or concern? How can the Humana Care Management team best support your patient?
Please list any chronic conditions/illnesses or behavioral health conditions.
Do any of these medical conditions require ongoing management and/or additional support? Please select all that apply.
Frequent adjustments to treatment plan (e.g., frequent visits to PCP/Specialist, ongoing medication monitoring, medical testing/labs, etc.)Inability or difficulty complying with scheduled appointments and tests (e.g., coordinating across specialties and services)Difficulty complying with medication regimen (e.g., consistent non-adherence, concerns about drug-to-drug interactions or not being on appropriate medication)Need for health education & support for building knowledge & self-management skills (e.g., signs and symptoms to be aware of, etc.)Recent changes to overall health (e.g., inability to perform daily activities)Other, please explain
Do you or your patient have concerns about their ability to self-manage and require of the resources below? Please select all that apply.
Transportation needs (for appointments and/or procedures)Financial assistance (for necessary medications or co-pays)Unsafe living environment (no access to bathroom, poor heating/cooling)Medical equipment (ramp/handrails needed)Food assistance (healthy meals)Other, please explain
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