Impact RESET Network - Client Interest & Eligibility Form

Welcome to the Impact RESET Network
If you have Medicaid and you're ready for change, complete this quick form so our care team can verify your eligibility and connect you to the right resources.

The Impact RESET Network offers therapy, coaching, housing, job support, and community support - at no cost through Medicaid.

You don't have to start over alone - you just have to RESET.

Medicaid & Case Information
Do you currently have Medicaid?*

YesNoNot Sure
Insurance Company
Medicaid ID Number (if known)
Case Manager Name (if known)
Case Manager Phone or Email (if known)
Who is your primary care provider (PCP)? *
(Example: Dr. Taylor Johnson, Goldsboro Family Medicine, 919.555.1234)
Would you like us to coordinate care or verify information with your PCP?*

YesNo
Authorization to Contact My Doctor’s Office
By checking below, I give Impact RESET Network / Impact Home Care Solutions permission to contact my primary care provider (PCP), therapist, or other healthcare provider to help determine my eligibility for services, verify medical information if needed, and coordinate referrals.

This authorization:

• Only allows communication related to service eligibility and coordination.

• Does not permit the release of detailed medical records without further written consent.

• Will remain valid for 12 months unless I revoke it in writing.
Please select your consent preference*

Yes, I authorize Impact RESET Network / Impact Home Care Solutions to contact my provider(s) for eligibility and coordination.No, I do not authorize contact at this time (I understand this may delay eligibility confirmation).
Thank you for your interest! The Impact RESET Network currently serves individuals with active Medicaid coverage. If you would like information about other Impact programs or private pay options, please call us at 919.988.8145.

Welcome to the Impact RESET Network