HHUNY Online Community Referral

*Fields are required

1. Contact Information for Person Completing Referral

Referrer First Name*:

Referrer Last Name*:

Referrer Title:

Organization*:

Referrer Phone*:

Referrer Email*:

Preferred/Recommended Care Management Agency (if any):

If the referral is for a youth between the ages of 18-21, please complete the following and check all that apply.

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

Is the youth in Foster Care? If yes, please contact your local LDSS

Please DO NOT COMPLETE THIS FORM. Contact your local LDSS for further direction.

Does the youth prefer to be served under the adult HH system?

Does the youth prefers to be served under the children’s HH system? (Please contact the correct HH based on county: https://www.health.ny.gov/health_care/medicaid/program/medicaid_health_homes/hh_map/)

2. Identifying Information of Person Needing Services

First Name*:

Last Name*:

Date Of Birth (mm/dd/yyyy):

Select Gender:

Address*:

City*:

Zip Code*:

County*:

CIN*:

CIN has 8 characters total: 2 letters, 5 numbers, 1 letter. e.g. - ab12345c

If CIN unavailable, provide SS # in narrative below (Section 5).

Phone:

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

3. Eligibility Category Information - Check All that Apply

Must meet either:

A only
B only
A and any number of C's
B and any number of C's
Two or more C's to be eligible

Make sure to specify the diagnosis.
E.g. - Serious mental illness - 296.8 Bipolar Disorder NOS
E.g. - Other chronic conditions - COPD

A - Serious mental illness

Please Provide Details:

B - HIV/AIDS & the risk of developing another chronic condition

Please Provide Details:

B - Sickle Cell Disease

C - Mental Health condition

Please Provide Details:

C - Substance Abuse Disorder

Please Provide Details:

C - Asthma

Please Provide Details:

C - Diabetes

Please Provide Details:

C - Heart Disease

Please Provide Details:

C - BMI > 25

Please Provide Details:

C - Other Chronic Conditions (Specify)

Please Provide Details:

4. Risk Factors - Check All that Apply

Give some detailed information concerning member's risk factors

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

Probable risk for adverse event, e.g. death, disability, inpatient or nursing home admission

Please Provide Details:

Lack of or inadequate social/family/housing support

Please Provide Details:

Lack of or inadequate connectivity with healthcare system

Please Provide Details:

Non-adherence to treatments or medication(s) or difficulty managing medications

Please Provide Details:

Current Inpatient

Please provide expected date of release:

Current Incarceration

Please provide expected date of release:

Recent release from incarceration

Please provide date of release:

Recent release from psychiatric hospitalization

Please provide length of stay:

Please provide discharge date (mm/dd/yyyy):

Please provide location of hospitalization:

Deficits in activities of daily living such as dressing, eating, etc.

Please Provide Details:

Learning or cognition issues

Please Provide Details:

Suicidal Ideation

Please Provide Details:

Homicidal Ideation

Please Provide Details:

History of Suicide Attempts

History of Incarceration

Please Provide Details:

History of Violence

Please Provide Details:

Legal History

Please Provide Details:

Unsafe Living Environment

Please Provide Details:

Sex Offender status and level

Please Provide Details:

CM Visitation Concerns (e.g. household hazards, safety factors)

Please Provide Details:

Other (please specify)

Please Provide Details:

5. Narrative

Provide any additional information that may be helpful in assignment to a care management agency

Narrative:

Disclaimer and Consent Form

Please, before checking box, 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.
By checking this box, I acknowledge I have received permission from the person under Section 2 to share their information with HHUNY and HHUNY affiliated Health Homes for the purpose of coordinating the delivery of services and related health care operations.

Please click on attachment A to view the list of agencies and organizations that your information may be disclosed to, only when necessary for your referral to be processed.
Attachment A for Central Region
Attachment A for Finger Lakes Region
Attachment A for Southern Tier Region
Attachment A for Western Region