24-hour follow up for patients who have Maryland Physicians Care
The purpose of this program is to help improve patient safety and satisfaction by providing early follow up for patients after a hospital visit via telemedicine with an ED physician through the MyVirtualMPC app (accessible via smartphone or computer with internet access). This program does not replace follow up with primary care providers and specialists, however, it can help bridge the care of the patient until definitive care is provided. We will attempt to reach the patient 3 times via the phone number you provide us, and/or through the MyVirtualMPC app (if the patient has activated his/her account).

This is a HIPAA compliant form. Only for active members of Maryland Physicians Care. This service is provided with NO CHARGE to the patient.
**Note: In order for patient to be able to use this service, the patient will need access to either a smart phone or an internet enabled computer. The patient must register on http://MyVirtualMPC.com.

Patient first name *
Your answer
Patient last name *
Your answer
Patient date of birth *
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Patient MOBILE phone number *
Please CONFIRM ACCURACY with the patient. **Please tell the patient to expect a text messaging inviting him or her to the MyVirtualMPC program, with instructions on how to get started.
Your answer
Sending facility *
Sending provider (or case manager) name *
Your answer
Sending provider (or case manager) phone number *
Your answer
Description of active medical issue, follow up plan, and relevant medical history. *
The more information you provide, the better care we can provide. We generally do not have access to the patient medical record, so please include relevant allergies, PMH, medication plan, treatment plan, follow up plan, and any special concerns (e.g. "Well controlled NIDDM with mild cellulitis, allergic to sulfa, discharged on doxy 100 bid x 10 d, please make sure rash is not spreading, if worsening return to ED for IV abx.")
Your answer
Would you like a call back?
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