RAW2HHC CLIENT REFERRAL& INTAKE FORM

RAW2HHC – Client Referral & Intake

Complete this form accurately and in full.
Please use accurate and consistent responses throughout this form.
Referral Source
Referral Source Name

First NameLast Name
Organization
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Client Information
Client Name

First NameLast Name
Date of Birth

MonthDayYear
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Medicaid Eligibility Information
Medicaid ID / Member ID
Medicaid Plan if known
Acknowledgment
Waiver / Program Type
Case Manager / Care Coordinator Name
Case Manager / Care Coordinator Phone or Email
Approved Hours, if known
Requested Start Date

MonthDayYear
Date
Is the client currently receiving services from another provider?
RAW2HHC may contact the case manager, care coordinator, health plan, or referral source to review eligibility, authorization, and next steps.
Upload authorization, care plan, or supporting documents if available

Cancelof
Service Request
Type of Services Needed

Other / Not Sure
Urgency
Urgency Level
Transportation Needed
Transportation Needed?
Pickup Location
Drop-off Location
Notes
Additional Notes
All information provided must be accurate and complete. False or incomplete information may affect service eligibility or result in delays.
Submitter Name

First NameLast Name
Signature
Date

MonthDayYear
Date
Should be Empty:

RAW2HHC – Client Referral & Intake