Healthcare Population Health Analytics Referral Form

Streamline Population Health Referrals with Smart Risk Assessment

Managing patient referrals while identifying care gaps and stratifying risk levels is critical for modern healthcare systems transitioning from retail health to comprehensive population health management. This Healthcare Population Health Analytics Referral Form template gives providers, care coordinators, and health systems a structured way to capture essential patient information, assess risk factors, identify care gaps, and recommend data-driven interventions—all in one streamlined digital form.

Built specifically for healthcare providers, population health managers, care coordinators, and medical practices implementing value-based care models, this template replaces fragmented referral processes with a unified approach that supports predictive modeling and intervention targeting.

Capture comprehensive patient data for better outcomes

This form guides referring providers through capturing demographic information, clinical history, current diagnoses, medication lists, social determinants of health, and recent utilization patterns. By systematically collecting this information upfront, receiving specialists and care teams can immediately assess patient complexity, identify gaps in preventive care, and prioritize interventions based on risk stratification.

The template includes conditional logic to reveal relevant follow-up questions based on chronic conditions, ensuring you capture the depth of clinical context needed for accurate risk assessment without overwhelming providers with unnecessary fields.

Risk stratification and care gap identification

Healthcare organizations using this template can implement standardized risk scoring methodologies by collecting key indicators including chronic disease burden, recent hospitalizations, ER utilization, medication adherence challenges, and social barriers to care. The structured format supports both manual clinical judgment and integration with predictive analytics platforms.

Care gap identification sections prompt referring providers to flag missing preventive services, overdue screenings, medication management issues, and follow-up appointments that haven't occurred—creating immediate visibility into opportunities for intervention and care coordination.

Designed for population health workflows

Whether you're managing ACO populations, implementing chronic care management programs, coordinating transitions of care, or running high-risk patient interventions, this form template provides the foundation for data-driven care coordination. The structured submission data integrates seamlessly with care management platforms, EHR systems, and population health analytics tools.

Automate referral workflows with Stepper

Connect this referral form to Stepper to automatically route referrals based on risk level, trigger care coordinator assignments for high-risk patients, create follow-up tasks in your project management system, update patient records in your EHR or CRM, and send customized care plans to patients and providers. Stepper's AI-native workflow automation ensures no referral falls through the cracks and high-risk patients receive immediate attention.

Secure, compliant, and ready to deploy

Built on Paperform's SOC 2 Type II compliant platform, this template supports secure patient data collection with the professional appearance and conditional logic healthcare organizations need. Customize the risk assessment criteria, care gap categories, and intervention options to match your organization's protocols, then embed the form in your patient portal, provider website, or care coordination platform.

Start transforming your referral process from simple handoffs to strategic, data-informed care coordination that improves outcomes and supports your population health objectives.