Community Referral For Health Home Care Management Services Page 2
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6HHUNY Health Home Care Management -- Community Referral Application
Identifying Information
Name:
Date of Birth:
Gender:
Address:
Medicaid CIN #:
Medicaid Managed Care Organization Name:
County of Residence:
Phone:
Cell Phone:
Indicate any need for language/interpretation services; specify language spoken if other than English:
Eligibility Category Information – Check All that Apply
Must meet either A only or B only or two C to be eligible
Check
Category
Specify Diagnosis; Provide Available Detail
A
Serious mental illness
B
HIV/AIDS & the risk of developing
another chronic condition
C
Mental Health condition
C
Substance Abuse Disorder
C
Asthma
C
Diabetes
C
Heart Disease
C
BMI > 25
C
Other Chronic Conditions (Specify)
Chautauqua County Department of Mental Hygiene - Huther Doyle
Lake Shore Health Home Services - Onondaga Case Management Services
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Parent category: Medical