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.
Date
Date of Birth
Members Name, (LAST, FIRST, MI,) (Include any alias, nicknames or other names the child/youth may be known by):
Address:
City
ZIP
County of Residence
Gender
Male
Female
Language preference other than English (Including American sign language):
Members Home Phone #
Member's Cell Phone #
INSURANCE
MEDICAID/CIN #:
MCO PLAN NAME: (If any)
If a copy of Medicaid card available please attach
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 18 years or older
Member/self/individual under 18, but is a parent, pregnant, or married
DATE PERMISSION TO REFER WAS OBTAINED:
PARENT/LEGAL GUARDIAN or LEGALLY AUTHORIZED REPRESENTATIVE [I.E. MEDICAL CONSENTER]
Consenter's Name
Relationship to Member
Consenter's Address:
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip
Consenter's Email Address
Guardian's Home Number
Guardian's Cell Number
Is member in foster care
Yes
No
Unknown
FAMILY/RESIDENTIAL INFORMATION
Is member parent/guardian currently enrolled in a health home?
Yes
No
Unknown
If yes, family member name:
Relationship to Referred Member
If yes, home health name:
If yes, care management agency:
HEALTH HOME ELIGIBILITY CRITERIA
(* Note: if documentation is available to support any of these conditions please attach)
ELIGIBILITY TYPE(if ICD10 code available please provide)
Two or More Chronic Conditions. List Conditions:
1:
2:
OR
one of the following single qualifying conditions
Serious Emotional Disturbance (SED)
List Condition:
Complex trauma
OR
HIV/AIDS
Sickle Cell Disease
APPROPRIATENESS CRITERIA (Check all that apply)
At risk for adverse event (death, disability, inpatient or nursing home admission, mandated preventive services, or out of home placement)
Has inadequate social/family/housing support or serious disruptions in family relationships
Has inadequate connectivity with the healthcare system
Does not adhere to treatments or has difficulty managing medications
Has recently been released from incarceration, placement, detention, or psychiatric hospitalization
Has deficits in activities of daily living, learning or cognition issues
Is concurrently eligible or enrolled, along with either their child or caregiver, in a HealthHome
Referral Source:
Hospital
MCP
VFCA
LDSS
Preventive Services
Community Based Organization
School
Primary Care Physician
Mental Health Provider
Specialist
LGU
SPOA
Other Referral Source:
Referral Organization
Name of person making referral
Phone (of person making contact referral)
Email (of person making contact referral)
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