Primary Care Coordination - Welcome to My Practice

As a matter of introduction, I am a licensed Psychiatric Clinical Nurse Specialist in Massachusetts (License number 145820/NPI # 1184796617). My practice is located at 82 Marlborough St., Boston, MA where I provide psychiatric consultation, therapy and prescribe medication in the context of a comprehensive treatment plan several days a week. Additionally, I work at Harvard University Health Services (HUHS) as a CNS in the Counseling and Mental Health Services department. I have been in the practice of psychiatric nursing since 1982 and prescribing medication as part of the expanded role since 1997. Below, is a secure “Primary Care Provider Communication Form” to assist the care coordination process. I very much look forward to working with you regarding the care of our mutual patient.

Primary Care Communication Form for Kathleen Andolina, RN, CS, PC

Date*
MM slash DD slash YYYY
Please note you have received this form after our mutual patient has signed an "Authorization to Communicate Medical Information." Please feel free to share clinical concerns, questions or observations that would be helpful in advancing the health care goals for this patient. Thank you.
- Primary Care Provider Communication
- Specialist Communication
Re: Patient Initials, DOB
Initial(s) DOB
Provider Name*
First Last Title
Provider Email and/or Telephone*
Enter Email Confirm Email
Please describe current concerns or questions:
Do you have goals in your treatment that I might assist in?
Please describe the working diagnosis, symptoms, issues that are the target of therapy
How often do you recommend that I update you with progress and /or have the patient be in contact with you re: these current concerns?
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