Nyc Nurse-Family Partnership Referral Form - Department Of Health And Mental Hygiene
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2NYC NURSE-FAMILY PARTNERSHIP REFERRAL FORM
SE HABLA ESPAÑOL
ELIGIBILITY
To qualify for the NYC Nurse-Family Partnership (NFP) program, a woman or girl must:
• Be less than 28 weeks pregnant*
• Have no previous live births
• Be low-income
• Live in a targeted area (See eligible ZIP codes on reverse side.)
Eligibility exceptions:
All NYC girls under 18 years old are eligible, regardless of ZIP code.
✓
All women and girls are eligible if they are: homeless or incarcerated, in foster care, or involved
✓
in the juvenile justice system
INSTRUCTIONS
• Complete
and
of form.
Part 1
Part 2
• Mail or fax to the
patient’s nearest NFP location (see reverse).* You will be notified as to the enrollment status of each referral.
•
For foster care, homeless, incarceration and juvenile justice cases, send to Targeted Citywide Initiative.
•
If sending this referral via fax, please call to notify the site (HIPAA requirement).
*Please send ASAP: An NFP nurse needs to make the first home visit and obtain consent before the 28th week of pregnancy.
Patient/Client Information
Part 1
CIN# (required for ACS clients):
Name:
Age:
Birthdate:
Apt:
Zip:
Address:
Home Phone #:
Work Phone #:
Cell Phone #:
Email Address:
# of Weeks Pregnant:
LMP:
Expected Delivery Date:
Speaks English?
Preferred Language:
Yes
No
Additional Contact Person:
Relationship to Patient/Client:
Contact’ s Home Phone #:
Work Phone #:
Cell Phone #:
Patient agrees to provide the information above regarding her
Patient’s/Client’s Signature:
Date:
pregnancy and to be contacted by NFP:
Yes
No
Referring Agency/Practice Information
Part 2
Referring Staff Name:
Title:
Agency/Practice Name, Facility or Division:
Phone #:
Fax #:
Date:
Email Address:
Please see reverse side for ZIP code eligibility, and mail or fax
form to the indicated NYC Nurse-Family Partnership location.
NYC NURSE-FAMILY PARTNERSHIP
NYC DEPARTMENT OF HEALTH AND MENTAL HYGIENE
th
160 West 100
Street, Suite 228
New York, NY 10025
Tel: 646.364.0714 | Fax: 646.364.0782
Jan 2017
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