Font Size: A+ | Reset | A-
 
1-855-613-7659

HHUNY Online Community Referral

*Fields are required

1. Contact Information for Person Completing Referral

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

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

If yes, indicate :

2. Identifying Information of Person Needing Services

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

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

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

5. Narrative

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

Disclaimer

 
Please make sure you read our Consent Form

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