Refugee Health Navigation
Client Name
First Name
Last Name
Date of Interview
*
-
Month
-
Day
Year
Date
Name of Person conducting interview
*
Client Email
example@example.com
Client Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
-
Month
-
Day
Year
Date
Marital Status
*
Emergency Contact - Name and Phone
*
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Consent
Reviewed Navigate Health SOPs: Navigate Health is a CHW organization that is here to help you understand and afford your healthcare. We received your name from XXX, and you indicated that you would like help accessing healthcare. Is this still the case?
*
Yes
No
Do you consent to sharing certain information with us in order to refer you to a medical professional? We will be sharing the information that you provide to us today, and may share some additional information as well. You may revoke this consent at any time.
*
Yes
No
Do you consent to adding Navigate Health as an authorized representative with your healthcare providers?
*
Yes
No
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Health Needs
What are your health concerns?
Have you seen any doctors before (either here in the US or in your home country) to address this problem?
Do you need transportation to your first appointment?
Please Select
Yes
No
Do you have Rhode Island Medicaid?
Please Select
Yes
No
Medicaid ID Number
Other insurance ID Number
Medicaid Renewal Date (https://www.ri.gov/EOHHS/medicaid_renewal)
-
Month
-
Day
Year
Date
Upload Image of Insurance Card (text via Whatsapp or Google Voice)
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