Simple Health Services HSS Referral

HOUSING STABILIZATION SUPPORT REFERRAL FORM

HSS
IMPORTANT (Read Carefully)

It is essential to indicate on this form if services have been pursued with another Housing Stabilization Services (HSS) provider before approaching Simple Health Services In some cases, individuals may have engaged with other HSS providers, and their submissions to the Department of Human Services (DHS) may not be immediately reflected in the MNITS system. This can lead to delays in service provision as we await DHS approval or seek change requests. To avoid unnecessary delays and ensure efficient service processing, kindly inform us if the individual has already sought services from another HSS provider. This information will help us expedite the process and prevent duplicative submissions. Your cooperation is greatly appreciated, and it will enable us to provide the best possible support to our clients. If you are unsure, please call.
Is there another possible HSS provider*

YesNo
If Yes, please add provider Contact Info below
Submission Type*

Initial (Over 30 Days Expired or First Time Utilizing Housing Stabilization Support Services.)Change Request (Over 30 Days Expired or First Time Utilizing Housing Stabilization Support Services.)
Type of support needed*

TransitioningSustaining
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
PMI Number or Social Security Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number(s)*
Email Address
example@example.com
Religious & Cultural Preference(s)
Language(s) Spoken
Gender Identity
Cultural Considerations
Race/Ethnicity
Disability Type (please check all that apply)*

Mental IllnessSSI/SSIDDevelopmental DissabilitySubstance Use DisorderInjury or Illness with Extended IncapacitationLearning Dissability
Medical Equipment, Devices, Adaptive Aides or Technology.
Guardian Status*

Self Guardian 1PrivatePublicUnder Commitment
Housing Instability*

HomelessAt Risk of HomelessnessTransitioning from FacilityInstitutional Level of Care/Waiver Eligible
Current Living Situation*

Own housing: Lease, Mortgage or RoommateService Provider: Foster Care or Group HomeJail/Prison/Juvenile DetentionFamily/Friends due to Economic HardshipHospital/Treatment/Detox/Nursing HomeEmergency ShelterHotel/MotelA Place not meant for Housing
Does this person currently have a source of income?*

YesNo
If yes, what types of Income?
Is this person currently homeless?*

YesNo
If yes, for how long?
Does this person have any mobility concerns?*

YesNo
Does this person currently have a lease?*

NoYes
If yes, when will the lease end?
How soon does this person want/need to move?*
Does this person use any of the following to assist with mobility?

CaneWalkerWheelchairScooterOther
Will this person need transitional services? (select all that apply)

DepositMoversHousehold ItemsFurniture
Will there be moving expenses?

YesNo
by selecting an option below I am a testing that myself or the person is leaving this living situation.

Leaving a Medicaid funded InstitutionCurrently homeless and has stayed in a shelter / County funded emergency shelter (including hotel voucher program or other County funded emergency housing sites) at some point over the last 12 months (by checking this option I attest myself or the person has self-reported shelter / County funded emergency shelter stay in the past 12 months)Leaving a provider controlled setting
How did you hear about Simple Health Services?*
Team Contact Information

Emergency Contact
Emergency Contact Name

First NameLast Name
Emergency Contact Company Name
Emergency Contact Phone Number
Please enter a valid phone number.
Emergency Contact Email
example@example.com

Waiver Case Manager
Case Manager Name

First NameLast Name
Case Manager Company Name
Case Manager Phone Number
Please enter a valid phone number.
Case manager Email
example@example.com

Targeted Case Manager
TCM Name

First NameLast Name
TCM Company Name
TCM Phone Number
Please enter a valid phone number.
TCM Email
example@example.com

Legal Representative or Guardian
Guardian Name

First NameLast Name
Guardian Company Name
Guardian Phone Number
Please enter a valid phone number.
Guardian Email
example@example.com

Referring Party
Referring Party Name*

First NameLast Name
Referring Party Company Name*
Referring Party Phone Number*
Please enter a valid phone number.
Referring Party Email Address*
example@example.com
Referring Party Signature*

Clear
Date*

MonthDayYear
Date
NOTE: For individuals with MA, there are two other forms that need to be filled out after this one. They are linked on the Submission confirmation page that pops up after you click the submit button. Please be sure to fill them out as it significantly decreases the processing time.

HOUSING STABILIZATION SUPPORT REFERRAL FORM

IMPORTANT (Read Carefully)

Team Contact Information