Referral Form
Medicaid Health Home Program
DEMOGRAPHICS
Member Name
*
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Member Address
Member Phone Number
*
Please enter a valid phone number.
Other Phone Number
Please enter a valid phone number.
Preferred Language
Please Select
English
Spanish
Chinese
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, list name of MCO
DIAGNOSIS
Members must be diagnosed with at least one of the Single Qualifying Conditions and/or at least Two Qualifying Chronic Conditions :
Single Qualifying Conditions
HIV / AIDS
Sickle Cell Anemia
Serious Mental Illness (specify below)
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
Two or More Qualifying Conditions
Asthma
Cancer (active)
Chronic Kidney Disease (CKD)
Chronic Liver Disease / Hepatitis C
Chronic Obstructive Pulmonary Disease (COPD)
Congestive Heart Failure (CHF)
Coronary Artery Disease / Cardiovascular Disease (heart failure/stroke)
Diabetes
Hypertension
Mental Illness (any not listed as an SMI)
Neurological Disorders (epilepsy, MS, Parkinson's, etc.)
Obesity
Substance Use Disorder
Other (1)
Other (2)
Other Chronic Conditions (specify below)
Please provide supportive documentation of diagnoses
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APPROPRIATENESS / RISK FACTORS
Check at least one risk factor that applies
At risk for serious health event
High risk of hospitalization, nursing home placement, disability, or death
Difficulty with daily functioning
Problems with activities of daily living, learning, or cognition
Disconnected from healthcare
No regular doctor or care team, difficulty keeping appointments, or hasn’t seen provider in the last year
Recent hospital, ER, or justice involvement
Discharged from inpatient, ER, detox, or crisis setting in past 6 months
Released from jail, prison, or justice program in past 6 months
Limited social or housing support
Lacks stable housing, food, or family support
Experience of family violence, intimate partner violence, or loss of primary caregiver
Difficulty managing treatment or medication
Non-adherence to treatment, confusion about medications, or lack of support managing care
Referral by protective or social service programs
Adult Protective Services or other official referral source
SERVICES NEEDED
MEDICAL / PHYSICAL HEALTH NEEDS
Chronic disease management
Crisis / Emergency Support (for members at high risk of hospitalization or ER use)
Medication management / adherence support
Preventative care (screenings, immunizations)
Primary care services
Specialty care services
BEHAVIORAL HEALTH NEEDS
Mental health treatment (therapy, psychiatry, crisis intervention)
Substance use treatment (outpatient, inpatient, detox, recovery supports)
Care coordination with mental health providers
Crisis / Emergency Support (psychiatric/substance-related)
SOCIAL & COMMUNITY SUPPORT NEEDS
Housing stability (shelter placement, supportive housing, eviction prevention)
Food access (SNAP, food pantries, meal programs)
Employment and vocational services
Education / literacy supports
Transportation assistance (medical transport, bus passes)
Legal aid (immigration, custody, benefits appeals)
FUNCTIONAL DAILY LIVING NEEDS
Assistance with activities of daily living (ADLs/IADLs)
Home health services / personal care aides
Durable medical equipment (wheelchairs, oxygen, etc.)
Peer support services
FAMILY & CAREGIVER SUPPORTS
Respite services for caregivers
Family counseling / parenting supports
Linkage to child and family services
BENEFITS & ENTITLEMENTS SUPPORT
Medicaid / Medicare enrollment and recertification help
SSI/SSD, unemployment, or other benefit access
Health insurance navigation
OTHER
Help connecting to multiple service providers / ongoing care coordination
Other (specify below)
OTHER NEEDS (please specify)
REFERRAL SOURCE
Referral Source Name
*
Referral Source Contact
*
Referral Source Phone Number
*
Please enter a valid phone number.
Referral Source Email
*
example@example.com
Relationship to Member
CareCollab Staff Contact
Additional Notes
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