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FEGS / Suffolk Wellness Partners Health Home

445 Oak Street, Copiague New York 11726


Phone: (631) 691-7080 x248 / Fax: (631) 798-1845

CARE COORDINATION COMMUNITY REFERRAL


Medical, Behavioral Health & Substance Abuse Care Management Services

Date:
Last Name

First Name

SSN

Address:
Street

Apt.

Town

Alt.
Address:

State

Street

Zip

Apt.

Town

State

Zip

AKA (also known as):


Home Phone:

Mobil Phone:

Alt. Phone:

E-mail address:

DEMOGRAPHIC INFORMATION
DOB:
Race:

Age:
White
Black

Hispanic/Latino
Asian

Gender:
Male
Alaskan Native
American Indian

Female
Transgender
Native Hawaiian
Pacific Islander

Other, specify:
Ethnicity:
Hispanic
Not Hispanic
Primary Language (spoken at home):
English
Spanish
Other (specify):
Primary Language During Service Provision:
English
Spanish
Other (specify):
If necessary, who will interpret?

ENTITLEMENTS
Medicaid
Medicaid Managed Care
Medicare
Private Insurance
No Insurance

Medicaid Number:
Medicaid Number:
Managed Care Provider:
Medicare number:
Insurance Provider:

REFERRAL SOURCE
Self, family or friend
Mental Health outpatient
Mental Health inpatient
Mental Health residential
Substance Abuse Program

MR/DD Facility
General Hospital ER
General Hospital (inpatient)
Other medical provider

Family Court
Criminal Court
Parole
Probation

BHO
Other Health Home:
specify:

Jail, penitentiary, etc.

REFERRAL INFORMATION
Name
Address:
Agency:
Phone #:
FEGS / Suffolk Wellness Partners Health Home

Title:

Ext:
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Applicant:

Medicaid #

PSYCHIATRIC DIAGNOSIS (including substance abuse)


Axis I

Axis II
Axis III
Axis IV
Axis V

Current:

Past Year:

ALL MENTAL HEALTH AND SUBTANCE ABUSE PROGRAMS MUST INCLUDE


PSYCHOSOCIAL AND PSYCHIATRIC EVALUATIONS
MEDICAL DIAGNOSIS (check all that apply)
Asthma
Diabetes
Heart Disease
Other, please specify:

Hypertension
Obesity (BMI >25)
HIV/AIDS

ATTACH AVAILABLE SUPPORTING DOCUMENTATION OF MEDICAL DIAGNOSIS


MENTAL HEALTH/SUBSTANCE ABUSE/MEDICAL PROVIDERS, if known
Outpatient MH Treatment Provider
Name
Phone
Outpatient Substance Abuse Provider
Name
Phone
Primary Health Care Provider
Name
Phone
Other Medical Provider
Name
Specialty:
Phone
Other Medical Provider
Name
Specialty:
Phone

APPROPRIATENESS FOR HEALTH HOME (Significant behavioral, medical or social risk factors that can be addressed
through care coordination) CHECK ALL THAT APPLY AND EXPLAIN BELOW
Probable risk for adverse event, e.g., death, disability, inpatient or nursing home admission
Lack of or inadequate social/family/housing support
Lack of or inadequate connectivity with healthcare system
Non-adherence to treatments or medication(s) or difficulty managing medications
Recent release from incarceration or psychiatric hospitalization
Deficits in activities of daily living such as dressing, eating, etc.
Learning or cognitive issues
Rationale (provide explanation/information/examples of items checked above, e.g., client is a BOCES graduate with cognitive
impairments and diabetes who has lost his support network and is having difficulty keeping appointments):

FEGS / Suffolk Wellness Partners Health Home

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Applicant:

Medicaid #

-------------------------------------------------------------------------------------------THIS SECTION FOR HEALTH HOME Referral Unit USE ONLY


Medicaid Eligible (confirmed through E-Paces):
Health home eligibility (confirmed through HCS Portal)

Yes
Yes

Referred to CMA Partner:


EOC
FSL
Federation

OPTIONS

FEGS

NYS

No
No

OUTREACH

PK

TRI-CARE

Other, specify:

HH Reviewer Print Name

HH Reviewer Signature

Date

--------------------------------------------------------------------------------------------

FEGS / Suffolk Wellness Partners Health Home

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