MiSide Health-Related Social Needs Screening Tool (Base Form)

MiSide Health-Related Social Needs Screening Tool
Privacy Statement
Please review the MiSide Privacy Statement by following the links below:
- MiSide Privacy Statement (English)
- MiSide Privacy Statement (Spanish)
I have reviewed and understand the MiSide Privacy Statement
This tool was derived from the Centers for Medicare & Medicaid Services (CMS) Accountable Health Communities (AHC) Health-Related Social Needs (HRSN) Screening Tool. CMS secured permissions from the original authors of the screening questions in the AHC HRSN Screening Tool to use, copy, modify, publish, and distribute the questions for the AHC Model and CMS use only. This table specifies the preferred citation and tracking process for each screening question in the AHC HRSN Screening Tool if the questions are used outside of CMS and the AHC Model.

Demographics
Name

First nameLast name
Date of birth

MonthDayYear
Phone number
Address
Zip Code
Email address
example@example.com
Preferred language
Race/Ethnicity

American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Pacific IslanderSpanish, Hispanic or LatinoWhite (Caucasian)Prefer not to answerOther
Gender Identity
Education Level
Employment Status
Monthly household/ annual income
This tool was derived from the Centers for Medicare & Medicaid Services (CMS) Accountable Health Communities (AHC) Health-Related Social Needs (HRSN) Screening Tool. CMS secured permissions from the original authors of the screening questions in the AHC HRSN Screening Tool to use, copy, modify, publish, and distribute the questions for the AHC Model and CMS use only. This table specifies the preferred citation and tracking process for each screening question in the AHC HRSN Screening Tool if the questions are used outside of CMS and the AHC Model.

Consent Statement
I understand that my healthcare information may be shared between staff at MiSide. My information may also be shared with my Primary Care Physician, specialists and Health Plans to ensure payment, confirm benefit entitlements, determine medical necessity and validate orders and charges.I am a responsible individual, parent or guardian and hereby give MiSide permission and consent to provide evaluation, treatment and services. I voluntarily consent to receive communication in the form of calls, texts or emails from MiSide in order to coordinate my care and services. I understand that I may withdraw my consent at any time by contacting MiSide and requesting this consent be withdrawn
This tool was derived from the Centers for Medicare & Medicaid Services (CMS) Accountable Health Communities (AHC) Health-Related Social Needs (HRSN) Screening Tool. CMS secured permissions from the original authors of the screening questions in the AHC HRSN Screening Tool to use, copy, modify, publish, and distribute the questions for the AHC Model and CMS use only. This table specifies the preferred citation and tracking process for each screening question in the AHC HRSN Screening Tool if the questions are used outside of CMS and the AHC Model.
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