Service Catalog
Referrals
HHUNY - Adult Self Referral Form

HHUNY - Adult Self Referral Form

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A referral for Medicaid members to receive health home care management services through HHUNY affiliated health homes

*If this referral is for a child that is under 18 years of age STOP, do not continue this referral.

Your Preferred/Recommended Care Management Agency (if any)

*If you are a youth between the ages of 18-21, please complete the following:

Are you in Foster Care?

Are you in Foster Care? No Yes

*If you are a youth in Foster Care, please DO NOT COMPLETE THIS FORM and contact your local LDSS for further directions.

Do you prefer to be served under the adult Health Home system?

Do you prefer to be served under the adult Health Home system? Yes No

*If no, please contact the correct children's Health Home, based on county:

https://www.health.ny.gov/health_care/medicaid/...

1. Identifying Information of Person Needing Services

First Name

Last Name

Date of Birth (mm/dd/yyyy)

*If this referral is for a child that is under 18 years of age STOP, do not continue this referral.

Gender

Gender Male Female Other

Street Address

City

Zip Code

County

Medicaid ID Number (CIN)

*If CIN is unavailable, provide your SSN in "Medicaid ID Number(CIN)" field above

Phone Number (Include Area Code)

Indicate any need for language/interpretation services specify language spoken if other than English

2. Eligibility Category Information - Check All that Apply

Must meet one of the following to be eligible:

One single qualifying chronic condition from group A

Two or more chronic conditions from group B
- *Please Note - Substance use disorders (SUDS) are considered chronic conditions, but do not by themselves qualify an individual for Health Home services. Individuals with SUDS must have another chronic condition to qualify.

Make sure to specify the diagnosis.
E.g. - Serious Mental Illness - 296.8 Bipolar Disorder NOS
E.g. - Other Chronic Conditions - COPD

Eligibility Category Information:

A - HIV/AIDS & the Risk of Developing Another Chronic Condition

A - Serious Mental Illness

A - Sickle Cell Disease

B - Asthma

B - BMI > 25

B - Diabetes

B - Heart Disease

B - Mental Health Condition

B - Substance Abuse Disorder

B - Other Chronic Conditions

Please specify the diagnosis for HIV/AIDS & the Risk of Dev Another Chronic Condition selection:

Please specify the diagnosis for Serious Mental Illness selection:

Please specify the diagnosis for Sickle Cell Disease selection:

Please specify the diagnosis for Asthma selection:

Please specify the diagnosis for BMI > 25 selection:

Please specify the diagnosis for Diabetes selection:

Please specify the diagnosis for Heart Disease selection:

Please specify the diagnosis for Mental Health Condition selection:

Please specify the diagnosis for Substance Abuse Disorder selection:

Please specify the diagnosis for Other Chronic Conditions selection:

3. Risk Factors - Check All that Apply

Give some detailed information concerning your risk factors

E.g. - Is at risk for hospitalization due to non-adherence with medication

Risk Factors:

Give some detailed information concerning member's risk factors

E.g. - Member is at risk for hospitalization due to non-adherence with medication

Risk Factors:

Care Manager Visitation Concerns (e.g. Household Hazards, Safety Factors)

Current Incarceration

Current Inpatient

Deficits in Activities of Daily Living such as Dressing, Eating, etc.

History of Incarceration

History of Suicide Attempts

History of Violence

Homicidal Ideation

Lack of or Inadequate Connectivity with Healthcare System

Lack of or Inadequate Social/Family/Housing Support

Learning or Cognition Issues

Legal History

Non-Adherence to Treatments or Medication(s) or Difficulty Managing Medications

Probable Risk for Adverse Event, e.g. Death, Disability, Inpatient or Nursing Home Admission

Recent Release from Incarceration

Recent Release from Psychiatric Hospitalization

Sex Offender Status and Level

Suicidal Ideation

Unsafe Living Environment

Other

Please provide details for Care Manager Visitation Concerns selection:

Please provide details for Current Incarceration selection, including expected date of release:

Please provide details for Current Inpatient selection, including expected date of release:

Please provide details for Deficits in Activities of Daily Living selection, such as dressing, eating, etc.:

Please provide details for History of Incarceration selection:

Please provide details for History of Suicide Attempts selection:

Please provide details for History of Violence selection:

Please provide details for Homicidal Ideation selection:

Please provide details for Lack of or Inadequate Connectivity with Healthcare System selection:

Please provide details for Lack of or Inadequate Social/Family/Housing Support selection:

Please provide details for Learning or Cognition Issues selection:

Please provide details for Legal History selection:

Please provide details for Non-Adherence to Treatments or Medication(s) or Difficulty Managing Medications selection:

Please provide details for Probable Risk for Adverse Event, e.g. Death, Disability, Inpatient or Nursing Home Admission selection:

Please provide details for Recent Release from Incarceration selection, including date of release:

Please provide details for Recent Release from Psychiatric Hospitalization selection, including length of stay, discharge date, and location of hospitalization:

Please provide details for Sex Offender Status and Level selection:

Please provide details for Suicidal Ideation selection:

Please provide details for Unsafe Living Environment selection:

Please provide details for Other selection:

4. Narrative

Provide any additional information that may be helpful in assignment to a care management agency, including the SSN if the CIN was unavailable.

Narrative

Disclaimer and Consent Form

Before checking the box, please read our Consent Form.

By checking this box, I agree I have read the Consent Form and give permission to HHUNY and HHUNY affiliated Health Homes to use and disclose my records for the purpose of coordinating the delivery of services to me and related health care operations.

I agree

Please use the links below to view the list of agencies and organizations that the referred individual's information may be disclosed to, only when necessary for the referral to be processed.

Central Region
Finger Lakes Region
Southern Tier Region
Western Region

Your phone number

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File attachments associated with the ticket.

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Other Fields

Your name

Your first name

Your last name

Your email address

Verification Code