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INFORMATION FOR MEMBER CLUBS
Member clubs have the right to refer patients. This is a multi-step procedure requiring information form the patient, the patient's Physician, and the sponsoring club. The first step is to verify that the patient meets the financial eligibility requirements. The second step is to assure that the patient has been seen by a physician who provides a diagnosis and supporting information. The third step is for the patient to fill out and authorize the release of medical information to CPMC. The final step is for the sponsoring club to complete the application and forward all documentation to CPMC.
The first of the six forms below provides more detailed information on Patient eligibility and explains the Patient, Physician, and Club responsibilities. It also provides information on how and where to send the completed forms. The next three forms are the Patient Financial Statement, The Physician's Referral Form, and the Patient Release of Information, each of which must be sent to CPMC. Care should be taken to make sure that all of the information required is complete.
As a result of our current operation and relationship with the California Pacific Medical Center, we are starting a pilot program to reimburse each club part of the transportation expenses. The reimbursement is based on the mileage between the referring club location and San Francisco.
Attached below are two new forms. The first is the actual Reimbursement Request Form with instructions. The second form is an example of how to calculate the mileage needed by the above form.
Forms:
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