Referral Form
  • Referral Form

    Medicaid Health Home Program
  •  - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • MEDICAID INFORMATION

  • DIAGNOSIS

    Members must be diagnosed with at least one of the Single Qualifying Conditions and/or at least Two Qualifying Chronic Conditions :
  • Health Home Serving Children and Adults Chronic Conditions

    1. Neurological Disorders

    • Neurodegenerative, Neuromuscular, CNS Disorders
    • Alzheimer's Disease and Other Dementias
    • Dementing Disease
    • Multiple Sclerosis and Other Progressive Neurological Diagnoses
    • Neurodegenerative Diagnoses Except Multiple Sclerosis and Parkinson's
    • Progressive Muscular Dystrophy and Spinal Muscular Atrophy
    • Chronic Neuromuscular and Other Neurological Diagnoses (listed twice)
    • Extrapyramidal Diagnoses
    • Epilepsy
    • Hydrocephalus, Encephalopathy, and Other Brain Anomalies
    • Reduction and Other Major Brain Anomalies
    • Neurologic Neglect Syndrome
    • Neurofibromatosis
    • Persistent Vegetative State
    • Spina Bifida w/wo Hydrocephalus
    • Neuropathy / Peripheral Nerve Disorders
    • Alcoholic Polyneuropathy
    • Peripheral Nerve Diagnoses
    • Neurogenic Bladder
    • Movement / Gait Disorders
    • Gait Abnormalities
    • Spinal & Musculoskeletal Neurological Conditions
    • Disc Disease and Other Chronic Back Diagnoses w/wo Myelopathy
    • Spinal Stenosis

    2. Psychiatric & Behavioral Health

    • Attention Deficit / Hyperactivity Disorder
    • Eating Disorder
    • Conduct, Impulse Control, and Other Disruptive Behavior Disorders
    • Chronic Stress and Anxiety Diagnoses

    3. Congenital & Developmental Disorders

    • Apert’s Syndrome
    • Chromosomal Anomalies
    • Developmental Delay NOS/NEC/Mixed
    • Developmental Language Disorder
    • Cleft Lip and/or Palate
    • Major Congenital Bone, Cartilage, and Muscle Diagnoses
    • Major Congenital Heart Diagnoses Except Valvular
    • Major Respiratory Anomalies
    • Major Anomalies of the Kidney and Urinary Tract
    • Curvature or Anomaly of the Spine
    • Pelvis, Hip, and Femur Deformities
    • Postural and Other Major Spinal Anomalies
    • Gastrointestinal Anomalies
    • Prematurity – Birthweight < 1000 Grams
    • Extreme Prematurity – Birthweight NOS

    4. Hematologic & Immunologic Disorders

    • Aplastic Anemia / Red Blood Cell Aplasia
    • Chronic Hematological and Immune Diagnoses
    • Chronic Lymphoid Leukemia w/wo Remission
    • Chronic Non-Lymphoid Leukemia w/wo Remission
    • Acute Lymphoid Leukemia w/wo Remission
    • Acute Non-Lymphoid Leukemia w/wo Remission
    • Neutropenia and Agranulocytosis
    • Hemophilia Factor VIII/IX
    • Immune and Leukocyte Disorders 

    5. Endocrine, Metabolic & Nutritional Disorders

    • Diabetes w/wo Complications
    • Chronic Metabolic and Endocrine Diagnoses
    • Hyperthyroid Disease
    • Chronic Thyroid Disease
    • Pituitary and Metabolic Diagnoses
    • Chronic Endocrine, Nutritional, Fluid, Electrolyte and Immune Diagnoses
    • Hyperlipidemia
    • Obesity
    • Phenylketonuria

    6. Cardiovascular Disorders

    Cardiac Disease

    • Angina and Ischemic Heart Disease
    • Coronary Atherosclerosis
    • Coronary Graft Atherosclerosis
    • Malfunction Coronary Bypass Graft
    • History of Coronary Artery Bypass Graft
    • Cardiomyopathy
    • Congestive Heart Failure
    • Atrial Fibrillation
    • Valvular Disorders
    • Pulmonary Hypertension
    • Complex Cyanotic and Major Cardiac Septal Anomalies

    Vascular Disorders

    • Peripheral Vascular Disease
    • Leg Varicosities with Ulcers or Inflammation
    • Vasculitis
    • Connective Tissue Disease and Vasculitis
    • Chronic Disorders of Arteries and Veins

    Cardiac Devices & Complications

    • Cardiac Device Status
    • Defibrillator Status
    • Mechanical Complication of Cardiac Devices, Implants and Grafts

    7. Cerebrovascular Disorders

    • Cerebrovascular Disease w/wo Infarction or Intracranial Hemorrhage
    • History of Transient Ischemic Attack

    8. Pulmonary Disorders

    • Asthma
    • Chronic Obstructive Pulmonary Disease and Bronchiectasis
    • Chronic Pulmonary Diagnoses
    • Chronic Bronchitis
    • Cystic Fibrosis
    • Major Respiratory Anomalies

    9. Gastrointestinal Disorders

    • Chronic Gastrointestinal Diagnoses
    • Diverticulitis
    • Inflammatory Bowel Disease
    • Nephritis (GU but often grouped with systemic inflammation)
    • Gallbladder Disease
    • Chronic Pancreatic and/or Liver Disorders (Including Chronic Viral Hepatitis)
    • Blind Loop and Short Bowel Syndrome
    • Stomas / Tubes
    • Enterostomy Status
    • Gastrostomy Status
    • Intestinal Stoma Status

    10. Liver Disorders

    • Alcoholic Liver Disease
    • Cirrhosis of the Liver
    • Major Liver Disease except Alcoholic
    • Ascites and Portal Hypertension

    11. Genitourinary Disorders

    • Chronic Genitourinary Diagnoses
    • Benign Prostatic Hyperplasia
    • Prostate Disease and Benign Neoplasms – Male
    • Recurrent Urinary Tract Infections
    • Vesicoureteral Reflux
    • Neurogenic Bladder
    • Anomalies of Kidney or Urinary Tract
    • Major Anomalies of the Kidney and Urinary Tract
    • Stoma Status
    • Genitourinary Stoma Status
    • Vesicostomy Status

    12. Gynecologic Disorders

    • Endometriosis and Other Significant Chronic Gynecological Diagnoses
    • Chronic Gynecological Diagnoses

    13. Eye Disorders

    • Cataracts
    • Glaucoma
    • Macular Degeneration
    • Chronic Eye Diagnoses
    • Blindness or Vision Loss

    14. Ear, Nose, and Throat Disorders

    • Chronic Ear Diagnoses except Hearing Loss
    • Chronic Hearing Loss
    • Other Chronic Ear, Nose, and Throat Diagnoses

    15. Skin & Connective Tissue Disorders

    • Psoriasis
    • Chronic Skin Ulcer
    • Chronic Ulcers
    • Significant Skin and Subcutaneous Tissue Diagnoses

    16. Musculoskeletal Disorders

    • Osteoarthritis
    • Osteoporosis
    • Chronic Joint and Musculoskeletal Diagnoses
    • Crystal Arthropathy
    • Spondyloarthropathy and Other Inflammatory Arthropathies
    • Rheumatoid Arthritis
    • Joint Replacement
    • Fitting Artificial Arm or Leg
    • Significant Amputation w/wo Bone Disease

    17. Pain & Functional Disorders

    • Chronic Pain
    • Migraine
    • Acquired Hemiplegia and Diplegia
    • Acquired Paraplegia
    • Acquired Quadriplegia

    18. Malignancies (Cancers)

    • Solid Organ Cancers
    • Breast Malignancy
    • Colon Malignancy
    • Digestive Malignancy
    • Esophageal Malignancy
    • Genitourinary Malignancy
    • Gynecological Malignancies
    • Kidney Malignancy
    • Liver Malignancy
    • Lung Malignancy
    • Pancreatic Malignancy
    • Prostate Malignancy
    • Stomach Malignancy
    • Bone Malignancy
    • Brain and Central Nervous System Malignancies
    • Ear, Nose, and Throat Malignancies
    • Hematologic / Blood Cancers
    • Hodgkin's Lymphoma
    • Non-Hodgkin's Lymphoma
    • Multiple Myeloma w/wo Remission
    • Plasma Protein Malignancy
    • Other / Non-Specific Cancers
    • Malignancy NOS/NEC
    • Secondary Malignancy
    • Neoplasm of Uncertain Behavior
    • Kaposi's Sarcoma
    • Other Malignancies

    19. Infectious Diseases

    • Chronic Infections Except Tuberculosis
    • Secondary Tuberculosis

    20. Substance Use Disorders

    • Chronic Alcohol Abuse and Dependency
    • Cocaine Abuse
    • Drug Abuse Related Diagnoses
    • Opioid Abuse

    21. Renal Disorders

    • Chronic Renal Failure
    • Nephritis
    • Recurrent Urinary Tract Infections (overlaps)

    22. Status / Device / Post-Surgical Conditions

    • Bone Transplant Status
    • Cardiac Device Status
    • Defibrillator Status
    • Enterostomy Status
    • Gastrostomy Status
    • Genitourinary Stoma Status
    • Intestinal Stoma Status
    • Major Organ Transplant Status
    • Fitting Artificial Arm or Leg
    • Joint Replacement
    • History of Major Spinal Procedure
    • History of Hip Fracture Age > 64 Years
    • Tracheostomy Status
    • Ventricular Shunt Status
    • Vesicostomy Status
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  • REASON FOR REFERRAL

  • SERVICES NEEDED

  • REFERRAL SOURCE

  • Format: (000) 000-0000.
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