Health Home Referral - Essen Health Care

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

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

Middle

Last

Gender Required

Male
Female
Trans-person

Age Required

Please enter a number from 1 to 100.

Preferred language

Patient’s Current Living SituationRequired
Lives aloneCommercial SROLives with family member (parent)Shelter - transitional housingdouble 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 letter