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PACT Clinic Referral

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1 PACT Clinic Referral on Fri Nov 28, 2014 1:46 pm


How do I refer a patient to a PACT clinic at BI?

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2 Re: PACT Clinic Referral on Fri Nov 28, 2014 1:48 pm


Process for referral to off-site PACT clinic practices (Beth Israel)
1. Identify applicable patient.
a. 1 admit in 30 days OR
b. 2 or more admits in the past 6 months OR
c. 3 or more ED visits in the past 6 months

2. Complete the referral template below:

Medicaid ID:
Readmit History:
Medical Conditions:
Social picture:
Current PCP:
Other Providers on Care Team:
Primary reason for referral to PACT Clinic:
PACT clinic preferred location (MSH, MSBI, MSSL):
Patient’s Primary Language:

3. Email completed template to the site-specific contact (listed below), cc’ing:
a. The site Health Home Social Worker
b. Your clinical supervisor
c. Maria Basso Lipani
d. Arielle Rosner (Coordinator, Health Home)
e. and, Dr. Ramiro Jervis (IMA PACT Clinic Medical Director).

GMA PACT (Mount Sinai Beth Israel):
Linda Charles
(HH SW: Caroline Hoppenheim:

4. Coordinate with site-specific staff to schedule initial appointment and accompany patient to appointment. For questions regarding medical appropriateness confer with Dr. Ramiro Jervis.

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