STATE OF COLORADO - CCHAP
September 10, 2009
John Dolittle, MD
All the Animals Road
Mytown, CO 80999
Re: Mouse, Mickey
State ID: Z555555
Dear Dr. DoLittle:
The above named Medicaid recipient has been enrolled in the Client Over-Utilization Program (COUP). You have been selected as the client’s primary care physician.
This program monitors and discourages over-utilization of medical services for Medicaid clients. In the Client Over-Utilization Program the primary care physician will authorize necessary referrals and order all prescriptions.
As the COUP primary care physician you will be the only physician authorized to receive reimbursement for providing services to this client. Your name will appear as the client’s primary care physician when the Medical Information Card is accessed. Services rendered by another physician will not be sanctioned. This restriction applies unless an emergency occurs requiring a hospital or emergency department visit.
Please return the attached form indicating acceptance or denial of assignment as this client’s primary care physician. If you have any questions, contact me, the Client Utilization Coordinator at 303-866-3672 or ethel.smith@state.co.us. Thank you for your assistance in providing the best care to our clients.
Sincerely,
Ethel Smith
COUP and DME PAR Administrator
Health Care Policy and Financing Department
(Over)
I am willing to become the primary care physician for the above named client in the Client Over-Utilization Program.
| |
I am not willing to become the primary care physician for the above named client in the Client Over-Utilization Program.
| |
____________________________________ ______________________________
Signature Date
____________________________________
Print Name
____________________________________
Provider ID Number
Please Return to: Attn: Ethel Smith
Client Utilization Coordinator, 3rd Floor
Health Care Policy and Financing Department
1570 Grant Street
Denver, CO 80203
Fax 303-866-2573
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