Hudson Valley Care Coalition

Medicaid Health Home Referral Form

To qualify for Health Home services, you must

1

Have active Medicaid

If you are not on Medicaid or your enrollment has lapsed, we can help you navigate enrollment and eligibility.

2

Have two or more chronic conditions (e.g., asthma, diabetes, mental health, substance use) OR have a single qualifying condition such as:

HIV/AIDS, Serious Mental Illness (SMI), or Sickle Cell Disease. View the full list of qualifying conditions:
Health Home Chronic Conditions

3

And, have risk factors such as:

No primary care provider, difficulty managing medications, recent incarceration, unstable housing or limited family support, and other challenges with daily living activities.

Referral Form

Through our care management network, the Hudson Valley Care Coalition (HVCC) Health Home program connects eligible Medicaid members to FREE assistance managing their medical and behavioral health needs, appointments, and social services, like food and housing support. Health Home care management is designed for individuals with two or more chronic health conditions, serious mental illness, or other complex needs and risk factors. By completing the referral form below, you are taking the first step to help an individual access personalized, whole-person coordinated care that promotes stability, reduces unnecessary hospital visits, and improves long-term health outcomes.

Complete the referral form linked below and send via Secure Email to acruz@hvcare.net or fax to 914.488.6635.

Full Name

Phone Number

Date of Birth

Medicaid ID Number

Address

City

State

Zipcode

Was the patient informed of the Health Home program?

Yes No

Were you able to provide Health Home information for the patient to take home?

Yes No

Did the patient provide his/her verbal consent to make the referral to the Health Home?

Yes No

Referring Person Full Name

Referring Phone Number

Provider Organization

Additional Information or Reason For Referral

Medicaid Health Home Referral Form

To qualify for Health Home services, you must

1

Have active Medicaid

2

Have two or more chronic conditions (e.g., asthma, diabetes, mental health, substance use) OR have a single qualifying condition such as:

3

And, have risk factors such as:

Referral Form

For Providers

For Individuals

Contact Us

Medicaid Health Home Referral Form

To qualify for Health Home services, you must

1

Have active Medicaid

2

Have two or more chronic conditions (e.g., asthma, diabetes, mental health, substance use) OR have a single qualifying condition such as:

3

And, have risk factors such as:

Referral Form

Self-Screening Tool