Referral Form
Medicaid Health Home Program
Member Name
*
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Borough / County
Brooklyn
Bronx
Manhattan
Queens
Staten Island
Nassau
Suffolk
Westchester
Member Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Other Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Member Email
example@example.com
Preferred Language
Please Select
English
Spanish
Mandarin
Cantonese
French
Haitian-Creole
Italian
Korean
Russian
Other
If Other Language selected, list it here
Legal Gender
Please Select
Male
Female
Preferred Gender
Please Select
Male
Female
Trans-M
Trans-F
Non-Binary
MEDICAID INFORMATION
Medicaid ID / CIN Number
*
(ex. AB12345C)
What type of Medicaid does member have?
Please Select
Fee-For-Service (FFS)
Managed Care (MCO)
If MCO, select the name of MCO
Please Select
AETNA BETTER HEALTH
AFFINITY HEALTH PLAN INC
AFFINITY HEALTH PLAN-ENRICHED PLAN
AGEWELL NEW YORK LLC
AMIDA CARE INC
ANTHEM
CATHOLIC MANAGED LONG TERM CARE INC
CATHOLIC MANAGED LTCS MLTC
CENTERLIGHT HEALTHCARE PACE
CENTERS PLAN FOR HEALTHY LIVING LLC
ELDERPLAN INC MAP
ELDERPLAN INC., HOMEFIRST
ELDERSERVE HEALTH INC
EXCELLUS
EXTENDED MLTC LLC
FIDELIS CARE
FIDELIS CARE DUAL
HAMASPIK CHOICE
HEALTH FIRST PHSP INC
HEALTH INSURANCE PLAN OF GREATER NE
HEALTHFIRST HEALTH PLAN, INC
HEALTHFIRST PHSP PERS WELLNESS PLAN
HEALTHFIRST PHSP, INC
HEALTHPLUS HP LLC
HIP WESTCHESTER
HIP/NASSAU COUNTY
HLTH INSURANCE PLAN OF GTR NY
INTEGRA MLTC INC MLTC PARTIAL CAP
MA Eligible
METROPLUS HEALTH PLAN INC
METROPLUS PARTIAL CAP MLTC
METROPLUS PARTNERSHIP CARE SN
MONTEFIORE HMO LLC
MVP HEALTH PLAN, INC
SENIOR WHOLE HEALTH MAP
SENIOR WHOLE HEALTH OF NEW YORK MLT
UNITED HEALTHCARE OF NEW YORK
VILLAGE SENIOR SERVICES CORPORATION
VNS CHOICE
VNS CHOICE PLUS M/M
VNS CHOICE SELECT HEALTH SNP
DIAGNOSIS
A member qualifies for Health Home services in one of two ways: 1. With ONE of the conditions listed in 'Single Qualifying Conditions,' OR 2. With TWO OR MORE conditions from the 'Common Chronic Conditions' list. Please check all conditions that apply to the member, regardless of pathway.
Single Qualifying Conditions
HIV / AIDS
Sickle Cell Anemia
Serious Mental Illness
None of these apply
Please Specify Serious Mental Illness(s)
Agoraphobia
Bipolar Disorder
Dissociative Identity Disorder
Generalized Anxiety Disorder (GAD)
Major Depressive Disorder
Mood Disorder with Mania
Obsessive-Compulsive Disorder (OCD)
Panic Disorder
Personality Disorders
Post-Traumatic Stress Disorder (PTSD)
Schizoaffective Disorder
Schizophrenia
Common Chronic Conditions
Anxiety Disorder
Asthma
Cancer
Cerebrovascular Disease
Chronic Kidney Disease
Chronic Liver Disease
Chronic Pain
COPD
Diabetes
Heart Disease
Hypertension
Major Depression
Obesity
Substance Use Disorder
Other
If Other, please specify additional chronic conditions
*
Please provide supportive documentation of diagnoses
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REASON FOR REFERRAL
What is the primary reason for this referral?
*
Difficulty managing health conditions and care
Recent hospitalization or frequent ER use
Behavioral health or substance use needs
Housing, food, or basic needs instability
Difficulty engaging with providers or treatment
Safety or vulnerability concerns
Justice system involvement or reentry
Other
If Other, please specify primary reason for this referral
*
SERVICES NEEDED
Medical & Care Coordination
Primary care connection
Specialist coordination
Medication support
Appointment scheduling or follow-up
Behavioral Health
Mental health services
Substance use services
Crisis or stabilization support
Social & Community Supports
Housing support
Food assistance
Transportation assistance
Utilities or financial assistance
Functional & Daily Living
Help managing daily activities
Caregiver support
Home or community-based services
Benefits & Entitlements
Medicaid or insurance assistance
SSI / SSD / cash assistance
Other benefits support
Services List Export
Other Needs
Please describe any additional needs or context
REFERRAL SOURCE
Referral / Outreach Source Type
Provider referral (Referral from a specific provider or care team)
Facility referral (Referral or list provided by a hospital, clinic, shelter, or other facility)
Community or facility outreach event
CareCollab direct outreach
Self-referral
Referral Source Company Name
*
Referral Source Contact Name
*
Referral Source Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Referral Source Email
*
example@example.com
Relationship to Member
CareCollab Staff Contact
Additional Notes
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