1st Care Management transmits all information provided here via secure email to ensure the confidentiality, integrity, and availability of all electronic protected health information that is created, received, maintained, or transmitted pursuant to 45 CFR 164.306 (a)(1).
1st Care Management frequently reviews and modifies the security measures implemented under this subpart as needed to continue provision of reasonable and appropriate protection of electronic protected health information.

Please complete the form below.

Patient Information

Patient Information

Name *

Phone Number *

Address *

City *

Postal / Zip Code *

Referring Information

Referring Information

Organization

Person’s Name

Person’s Phone Number

Person’s Email

Before a patient is seen through 1st Care Management, we must have a complete medication list for this patient, Medical History, as well as any current test results.

Before a patient is seen through 1st Care Management, we must have a complete medication list for this patient, Medical History, as well as any current test results.

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If you do not have the above documents, please complete the following fields to allow 1st Care Management to request these documents on your behalf.

If you do not have the above documents, please complete the following fields to allow 1st Care Management to request these documents on your behalf.

Name of any physicians and medical facilities you’ve visits in the last 6 months.

Name of any physicians and medical facilities you’ve visits in the last 6 months.

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Permission to contact: *

I give 1st Care Management permission to contact the above providers to acquire my medical information for the purposes of providing me healthcare services through their agency. *

Security *

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Phone: (833) 633-4778
Fax:     (888) 622-6062
Email: This email address is being protected from spambots. You need JavaScript enabled to view it.
Address: 1120 Hope Rd Suite 210, Sandy Springs, GA 30350