NYP Health Home Referral Form
Date of Referral
Medicaid Number
Is this patient currently being treated at an NYP location?
Yes
No
Locations
--Select--
Allen
Westchester
CUMC
WCMC
LMH
Unit
Anticipated Discharge Date
Is this referral for the Metropolitan Center for Mental Health (MCMH)?
Yes
No
Preferred Language:
Insurance name:
Beneficiary (Primary Policy Holder):
Policy number:
DEMOGRAPHICS
NYP MRN(If known)
DOB(mm/dd/yyyy)
Last Name
First Name
Main Phone Number
Other Phone Number
Home Address
City
State
Zip
Has Referral been discussed with the patient?
Yes
No
Patient/Client resides in one of the following
Manhattan
Bronx
Brooklyn
Queens
For clients residing outside these geographical areas, please refer to the link below for participating health homes in New York State.
NYS Health Home Directory
REFERRER CONTACT
Referrer Type
--Select--
Care Management Agency
Health Home
Hospital Emergency Department
Inpatient Hospital
Managed Care Organization (MCO)
Other
Referrer Name
Unit/Clinic/Agency
Referrer Phone
Referrer Email
HEALTH HOME ELIGIBILITY
Patient/Client has ACTIVE Medicaid
Yes
No
Patient/Client meets the diagnostic eligibility criteria defined below
Yes
No
Two chronic condition (mark all they apply)
Mental Health Condition
Asthma/COPD
Heart Disease
Substance Use Disorder
Diabetes
Other (specify)
Please enter Other Condition
A Severe Mental Illness(Specify)
HIV/AIDS
Please Select At least 2 Conditions
SERVICES NEEDED(CHECK ALL THAT APPLY)
Chronically Ill
Dental Care/Vision Care
Entitlements Assistance
Family Therapy
GYN Care
Harm Reduction Referrals
In Home Services / Healthcare System
Appointment Reminders
Housing Advocacy and support
Mental Health/Counseling
Substance Use Treatment
TB Testing and Follow-up
Treatment Adherance / Education
Transportation
Food and Nutritional Services
Legal Services (Specify)
Other (Specify)
Please enter Other Service
Support Groups (specify type)
Please Select At least 1 Service
General Comments
Submit