HealthHome.Care Referral Form

If you need additional assistance please call: 1.800.589.6055

Instructions:

This form is to be completed in its entirety in order to make a referral to a Health Home. Please attach any clinical documentation to support eligibility.

1) Date of Birth

2) Member's Name (Last, First, MI,)*

3) Member's Current Address:

4) City, State , Zip

6) Gender:

Male

Female

Other

7) Language Preference:

English

Russian

Chinese

Spanish

Other

Yiddish

8) Member's Home Phone #:*

9) Member's Cell Phone #:

Insurance

10) Medicaid/CIN #:

Permission To Refer:

You must identify that consent to refer has been obtained and who has given consent to refer. Please note that this can be a verbal consent received.

Please indicate the individual from whom you have obtained consent to refer this member to the health home program

Parent

Guardian

Legally authorized representative

Member/self/individual if 18 years old or older

Member/self/individual under 18, but is a parent, pregnant or married

Parent/Legal Guardian or Legally Authorized Representative (I.E. Medical Consenter):

14) Consenter's Name:*

15) Relationship To Member:

16) Consenter's Address:

17) Consenter's City, State and Zip Code:

18) Consenter's Email Address

19) Guardian's Phone #:*

21) Is Member in Foster Care?

Yes

Unknown

Family/Residential Information

22) Is Member's Guardian Enrolled in Health Home?

Yes

23) If Yes, Family Member Name:

24) If Yes, Health Home Name:

25) If Yes, Care Management Agency:

26) Relationship To Referred Member:

Health Home Eligibility Criteria

(*Note: if documentation is Available to support any of these conditions please attach)

File Upload

Drag and drop files here or

Eligibility Type (If ICD10 code available please provide)

Two or More Chronic Conditions: Please List

28) 2

Or one of the following single qualifying conditions:

Serious Emotional Disturbance (SED)

Complex Trauma

HIV/AIDS

30) If Yes For SED List Condition

31)Appropriateness Criteria (Select all that apply

Select

33) Referral Source

Hospital

MCP

VFCA

LDSS

Preventive Services

Community Based Organization

School

Primary Care Physician

Mental Health Provider

Specialist

LGU

SPOA

Member/Parent

Other Referral Source

34) Referral Organization:

35) Name of Referrer:*

36) Referrer Phone:*

37) Referrer Email:

Enter contact name and phone number for follow up:

When is the best time to follow up?

Send me a copy of my responses

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