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 two (2) or more chronic conditions?(*)

Gender

I understand and agree that GBUAHN will be contacting me

15 + 3 =

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