---
title: Primary Care Value-Based Reimbursement Optimization Referral Form Template | Paperform
description: Comprehensive referral form for primary care practices participating in value-based care programs. Capture quality measures, document risk adjustment opportunities, close care gaps, and optimize VBC reimbursement.
url: "https://paperform.co/templates/primary-care-value-based-reimbursement-optimization-referral-form"
type: static
generatedAt: "2026-03-28T00:44:53.271Z"
---

[← Back to free form templates](/templates/)    ![Primary Care Value-Based Reimbursement Optimization Referral Form](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/primary-care-value-based-reimbursement-optimization-referral-form.png)
    [Preview](https://_preview.paperform.co/ai-template/primary-care-value-based-reimbursement-optimization-referral-form) [Use this template for free](/create?ai-template=primary-care-value-based-reimbursement-optimization-referral-form)    [Healthcare & Medical Forms](/templates/category/healthcare/) [Healthcare](/templates/industry/healthcare/) [Manager](/templates/role/manager/)[Physician](/templates/role/physician/)[Nurse](/templates/role/nurse/)[Healthcare Administrator](/templates/role/healthcare-admin/)     About this free form template
### Streamline Value-Based Care Referrals with Paperform

Healthcare providers operating in value-based reimbursement models face unique documentation challenges. This **Primary Care Value-Based Reimbursement Optimization Referral Form** helps primary care physicians, practice managers, and care coordinators systematically capture the clinical and quality data needed to maximize reimbursement while closing care gaps and improving patient outcomes.

#### Built for Modern Healthcare Workflows

Value-based care requires meticulous documentation of quality measures, HCC coding opportunities, and care coordination activities. This template is specifically designed for practices participating in ACO, MSSP, Medicare Advantage, or commercial VBC contracts. It ensures every specialist referral includes the comprehensive documentation needed for accurate risk adjustment, quality measure attribution, and care gap closure tracking.

Whether you're a primary care clinic, multi-specialty group, or healthcare system, this form helps you systematically document clinical complexity, capture RAF score opportunities, and track progress toward quality benchmarks—all while maintaining compliance with CMS and payer requirements.

#### Comprehensive Documentation That Drives Results

The form captures essential elements including patient demographics, current diagnoses with HCC mapping potential, active medications, relevant quality measures (HEDIS, STARS, MIPS), identified care gaps, and specific referral details. Built-in conditional logic ensures only relevant sections appear based on the referral type and clinical scenario, making completion faster while maintaining thoroughness.

#### Automate Your Value-Based Care Workflows

Connect this form with [Stepper](https://stepper.io) to automatically route referrals to appropriate specialists, update your EHR with quality measure progress, notify care coordinators of high-priority care gaps, and generate monthly population health reports. Integration with your practice management system, EHR, and analytics platforms means every submission contributes to your value-based performance without manual data entry.

Paperform's GDPR compliance and SOC 2 Type II certification provide the security healthcare organizations require, while the intuitive interface ensures your clinical and administrative staff can complete referrals efficiently. Transform your referral process from a documentation burden into a strategic asset for value-based success.
       Built for growing businesses, trusted by bigger ones.   Trusted by 500K+ business owners and creators, and hundreds of millions of respondents.     ![Capterra - 4.8 out of 5](/images/capterra-st.jpg)
 ![Trustpilot - 4.8 out of 5](/images/trustpilot-st.jpg)
 ![G2 - 4.8 out of 5](/images/g2-st.jpg)
  [Try Paperform free now](/register)
## More templates like this
  [![Obstetrician to Maternal-Fetal Medicine Specialist Referral Form](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/obstetrician-to-maternal-fetal-medicine-specialist-referral-form.png)

### Obstetrician to Maternal-Fetal Medicine Specialist Referral Form

A comprehensive referral form for obstetricians to refer high-risk patients to maternal-fetal medicine specialists, including ultrasound findings, genetic testing results, pregnancy complications, and relevant clinical information.](/templates/obstetrician-to-maternal-fetal-medicine-specialist-referral-form/)
[![Physical Medicine to Pain Management Specialist Referral Form](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/physical-medicine-to-pain-management-specialist-referral-form.png)

### Physical Medicine to Pain Management Specialist Referral Form

A comprehensive physician referral form for transferring patients from physical medicine to pain management specialists, including pain assessment, medication history, and functional limitations.](/templates/physical-medicine-to-pain-management-specialist-referral-form/)
[![Primary Care to Accountable Health Community Referral Form](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/primary-care-to-accountable-health-community-referral-form.png)

### Primary Care to Accountable Health Community Referral Form

A comprehensive whole-person care referral form enabling primary care providers to connect patients with accountable health communities through integrated medical, behavioral health, and social care coordination.](/templates/primary-care-to-accountable-health-community-referral-form/)
[![Primary Care to Cardiology Specialist Referral Form](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/primary-care-to-cardiology-specialist-referral-form.png)

### Primary Care to Cardiology Specialist Referral Form

A comprehensive referral form for primary care physicians to refer patients to cardiology specialists, including patient history, medications, symptoms, and insurance authorization details.](/templates/primary-care-to-cardiology-specialist-referral-form/)
[![Primary Care to Health Information Exchange (HIE) Referral Form](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/primary-care-to-health-information-exchange-hie-referral-form.png)

### Primary Care to Health Information Exchange (HIE) Referral Form

A comprehensive medical referral form for primary care providers to request health information exchange queries, coordinate cross-facility records, verify patient matching, and access longitudinal health data for specialist referrals.](/templates/primary-care-to-health-information-exchange-hie-referral-form/)
[![Primary Care to Medical Neighborhood Coordination Referral Form](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/primary-care-to-medical-neighborhood-coordination-referral-form.png)

### Primary Care to Medical Neighborhood Coordination Referral Form

Streamline specialist referrals with bidirectional communication, care plan alignment, and team-based coordination between primary care and specialist providers.](/templates/primary-care-to-medical-neighborhood-coordination-referral-form/)
[![Primary Care to Reproductive Endocrinology Referral Form](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/primary-care-to-reproductive-endocrinology-referral-form.png)

### Primary Care to Reproductive Endocrinology Referral Form

A comprehensive medical referral form for primary care physicians to refer patients to reproductive endocrinology specialists, including detailed fertility history, menstrual cycle tracking, hormone levels, and partner information.](/templates/primary-care-to-reproductive-endocrinology-referral-form/)
[![Urgent Care to Neurosurgery Referral Form](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/urgent-care-to-neurosurgery-referral-form.png)

### Urgent Care to Neurosurgery Referral Form

Streamline urgent neurosurgery referrals with comprehensive head injury assessment, Glasgow Coma Scale evaluation, CT scan results, and neurological deficit documentation.](/templates/urgent-care-to-neurosurgery-referral-form/)
[![Allergy & Immunology Records Transfer Form](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/allergy-immunology-records-transfer-form.png)

### Allergy & Immunology Records Transfer Form

Request and transfer comprehensive allergy and immunology medical records, including skin test results, immunotherapy protocols, anaphylaxis history, and emergency action plans between healthcare providers.](/templates/allergy-immunology-records-transfer-form/)
[![Catheterization Lab Emergency Evacuation Form](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/catheterization-lab-emergency-evacuation-form.png)

### Catheterization Lab Emergency Evacuation Form

A critical incident form for managing cath lab evacuations, tracking patient status, equipment shutdown, sterile field protocols, and staff accountability during emergency situations.](/templates/catheterization-lab-emergency-evacuation-form/)
[![Certified Wound Care Specialist Competency Evaluation](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/certified-wound-care-specialist-competency-evaluation.png)

### Certified Wound Care Specialist Competency Evaluation

A comprehensive competency assessment for wound care specialists covering debridement techniques, compression therapy, infection management, and documentation standards.](/templates/certified-wound-care-specialist-competency-evaluation/)
[![Clinical Laboratory Service Application](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/clinical-laboratory-service-application.png)

### Clinical Laboratory Service Application

A comprehensive application form for clinical laboratories to apply as service providers, covering test capabilities, specimen collection, insurance billing, result reporting, and stat testing services.](/templates/clinical-laboratory-service-application/)