ESSEN HEALTHHealth Home CMA (Care Management Agency) Referral Face Sheet The Health Home Referral Face Sheet Is there an urgent need for us to contact you immediately?(Example – Eviction, Food access, Loss of public entitlement, Urgent Medical or Psychiatric need) Yes No Member Demographic This form must be completed to generate a referral to Essen’s Health Home. Please attach any important documentation that supports the patient’s eligibility. Once you click submit, you will receive a copy of it in a secured email.Date Please Select(Required) Adult Children Youth Patient Demographics:Name(Required) First Middle Last Gender(Required) Male Female Trans-person If Trans-person(Required) Man Woman Age(Required)Please enter a number from 1 to 100.Preferred language:Select Preferred LanguageEnglishSpanishFrenchHaitian KreyolBengaliOtherOther, Then Please Specify It(Required) Patient’s Current Living Situation:(Required) Lives alone Commercial SRO Lives with family member (parent) Shelter - transitional housing double up (couch surfing) Fill Your Address Details(Required) Address City State Zip / Postal Code Cell Phone Number(Required)Alternative Phone Number(Required)Email Address(Required) Insurance Information:Medicaid CIN#(Required) Medicaid CIN must be Two letters followed by Five members and ends with One letterChronic ConditionsSingle Qualifying:(Required) HIV/AIDS Serious Mental Illness Serious Emotional Disturbance Complex Trauma Two or More of the following: Visit Here Patient has the following qualifying conditions:(Required) Appropriateness Criteria(Required) At risk for adverse event Has inadequate social/family/housing support or serious disruptions for family relationships Has inadequate connectivity with healthcare system Does not adhere to treatment or has difficulty managing medication Has recently been released from incarceration, placement detentions or psychiatric hospitalization Has deficits in ADL learning or cognitive issues Is concurrently eligible or enrolled along with either their child or caregiver in a Health Home – CMA Referral Source Information:Select Referral Source InformationMember/SelfEssen HealthACSCommunity Based organizationHomeless ShelterSPOAPrimary Care PhysicianPediatric clinicParentSchoolBehavioral Health ClinicOtherOther, Then Please Specify It(Required) Name of referred OrganizationName of the organization(Required) Name(Required) First Telephone #(Required)Email Address(Required)
