GBUAHN Referral

HEALTH HOME REFERRALS

New York State’s Health Home eligibility criteria is as follows:

Medicaid eligible/active Medicaid and two (2) or more chronic conditions; or one (1) single qualifying condition of either HIV/AIDS or a Serious Mental Illness (SMI)

All fields marked with an (*) are required.

Fill Out the Form Below

Do you have Medicaid Do you have Medicaid YES NO

What MCO do you currently have?(*)

Do you have two (2) or more chronic conditions?(*) Do you have two (2) or more chronic conditions?(*) Yes No

Message

Name

Gender Gender Male Female

Date of Birth

Address

City

State

Zip Code

Phone Number

Email Address

CIN

Religion

Primary Language

Secondary Language

Emergency Contact Name

Emergency Contact Phone Number

Source of Lead

Referral First Name

Referral Last Name

Referral Phone Number

If referral is urgent or you wish to share other information with GBUAHN, please explain

Enter your full name to represent your signature(*)

I understand and agree that GBUAHN will be contacting me I understand and agree that GBUAHN will be contacting me I understand and agree that GBUAHN will be contacting me

Questions and Comments

7 + 14 =