Referral Form
Adult Health Home Services
Who is completing this form?
*
Self
Liberty Resources Employee
Other Supporter
Client Information
County of Residence
*
Please Select
Cayuga
Madison
Monroe
Oneida
Onondaga
Oswego
Wayne
Client Name
*
First Name
Last Name
Client Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Client Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Client Cell Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Client DOB
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Client Gender Identity
*
Insurance Information
Medicaid CIN# (ex:AB12345C)
*
Managed Care Organization
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Consent to Refer
Who has provided you with consent to make this referral?
Client
Legally Authorized Representative
Consenter Information
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to Client
Contact Information for Referral Provider
Name
First Name
Last Name
Title
Organization
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
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Eligibility Criteria
Adults may be eligible by having two or more chronic health conditions or one of the following single qualifying conditions: HIV/AIDS, Serious Emotional Disturbance.
To the best of your knowledge, what chronic conditions, mental health diagnosis or complex trauma make you or the individual you are referring eligible for NYS Health Home services?
Reason for referral
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RISK FACTORS: Check all that apply
Needs connection to medical providers, and mental health or substance use providers.
Needs support to avoid hospitalization.
Needs help connecting with social/family/housing supports.
Requires support and advocacy with medical care.
Recently released from incarceration, placement, detention, or psychiatric hospitalization.
Has deficits in activities of daily living, learning or cognition issues.
Probable risk for adverse event (death, disability, inpatient or nursing home)
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