MCRT Follow-Up Logger
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MCRT Call Follow up Logger
Call #:
Name:
DOB:
Member Phone#:
Beacon ID:
Date of Call:
Date to Follow Up:
Dispatch Caller (Name & #):
Person to Call Back:
Insurance Type:
-- Select --
Medi-Cal
Medicare
Private
Unknown
Consent Forms/ROI Signed?:
Resources Given:
Resources Requested:
Additional Resources To Prevent Recurring Crisis:
Level of Risk:
Service Connected?:
Avatar EHR:
Details:
Next Steps:
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MCRT Follow-Up Logger
MCRT Follow-Up Logger