Step-by-Step Project
Access Dallas Patient Enrollment Process
Complete the following on-line forms with the patient:
1. Patient Profile
2. Enrollment Application
3. Health Risk Assessment
4. SF8
5. Enter information in the Contact Log regarding why the patient is
being referred to PA and where they came from, and what their medical
issues are. If you are a charity medical clinic enrollment site, use
code 1105 for new enrollments. If you are a hospital enrollment site,
use the appropriate code for your hospital.
Have the Patient sign the following forms:
1. Patient Consent for Service
2. Patient Rights and Responsibilities
3. HIPPA Authorization Form
E-mail
E-mail Connie Webster at connie@dallas-cms.org
to change the patient’s status to active, once the administrative
enrollment process is complete. Make sure in your e-mail to include the
patient’s name, PAD ID number, date of birth, and the date the enrollment
process was completed. If you need the patient to be turned on immediately,
you can call Kambria Kennedy at 214-948-3622, ext. 240.
Give the patient the following items:
1. Project Access Dallas ID card (make sure to put the
letters PA in front of the ID number & remind the patient about
the our program’s Patient Help Line, should the patient have any
questions or concerns – the phone number is printed on the patient’s
enrollment card).
2. Letter informing patient about the Project Access
Dallas Pharmacy Program.
3. Appointment Confirmation Form, which lists the patient’s
Medical Home (this applies only if you make the patient’s new
PCP appointment for them, during their enrollment process. If you make
the appointment after their enrollment visit with you, then you will
need to notify the patient by phone and/or send the appointment confirmation
form to them in the mail).
4. Provide the patient a copy of the consent forms they
signed. The forms are: Patient Consent for Service Form, Patient Rights
and Responsibilities Form, and the HIPPA Authorization Form.
Fax the following forms to Project Access
Dallas at
214-946-5805:
1. Patient Consent for Service
2. Patient Rights and Responsibilities
3. HIPPA Authorization Form
4. Patient’s Financial Information
5. Copy of the patient’s picture ID, which verifies their Dallas
residency
Fax the following to the patient’s Project Access
Dallas PCP:
Fax the Health Risk Assessment Fax Cover to the patient’s
Project Access Dallas PCP, if they screen positive on the mental health,
cancer or diabetes questions. Use the Project Access Dallas Fax Cover,
which lets the physician know that the patient has just been enrolled
in the DCMS community service project, Project Access Dallas, so that
they can file the patient’s Health Risk Assessment Fax Cover in
the patient’s chart, so that they can review it with the patient
at their next visit with the PCP.
Once the patient’s enrollment has been activated,
enter
them in the Caremark on-line website:
Enter the patient’s name, PAD ID number and date
of birth. If you do not have access clearance in the Caremark website,
contact Connie Webster at connie@dallas-cms.org
or 214-413-1426.
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Downloadable
documents: