Patient Nomination Form for UTP Project -- Submit 1 form for each patient

PLEASE DO NOT HIT THE BACK BUTTON ON YOUR BROWSER UNTIL YOU PRESS SUBMIT AT THE BOTTOM OF THIS FORM

CRITERIA FOR PATIENT NOMINATION
o Patient has gone through one or more transfers from one site to another
o Patient uses both healthcare and support services
o Patient has a complex health history
o Patient is English speaking

NOTE: You are free to nominate caregivers (using the caregiver nomination form) without nominating their patients, and vice versa.

For each person you nominate, please contact them to inform them that we will be calling to:

o Tell them about this state-wide project to improve the accuracy and timeliness of the health information their providers receive.
o Arrange a time to have a conversation with them to ask their opinion about the kind of information they believe it is important for their care providers to know about their health status when their care is transferred from one place to another (e.g. clinic to hospital; hospital to home health agency).
o Inform them that this will be completely confidential.

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    Patient Nomination

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