Referral Form (Adult)

referrals@carecollabs.com | (646) 450-1075 | www.carecollabs.com
Referral Form

Medicaid Health Home Program (Adult)
Adult Details
Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address

Street Address

Street Address Line 2

CityState

Postal / Zip Code
Borough / County
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.
Email
example@example.com
Preferred Language
If Other Language selected, list it here
Legal Gender
Preferred Gender
MEDICAID INFORMATION
Medicaid ID / CIN Number
(ex. AB12345C)
What type of Medicaid does member have?
If MCO, select the name of MCO
If MLTC, select the name of MLTC
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
Please Specify Serious Mental Illness(s)
Common Chronic Conditions
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?
If Other, please specify primary reason for this referral
SERVICES NEEDED
Medical & Care Coordination
Behavioral Health
Social & Community Supports
Functional & Daily Living
Benefits & Entitlements
Services List Export
Other Needs
Please describe any additional needs or context
REFERRAL SOURCE
Referral / Outreach Source Type
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
Should be Empty:

Referral Form

Adult Details

MEDICAID INFORMATION

DIAGNOSIS

REASON FOR REFERRAL

SERVICES NEEDED

REFERRAL SOURCE