Click For Care

ESSEN HEALTH

Health 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.

Adult
Children
Youth
Patient Demographics:

Male
Female
Trans-person

Please enter a number from 1 to 100.



Lives alone
 Commercial SRO
 Lives with family member (parent)
 Shelter - transitional housing
 double up (couch surfing)

Address
City
State
Zip / Postal Code



Insurance Information:

Medicaid CIN must be Two letters followed by Five members and ends with One letter

Chronic Conditions

HIV/AIDS
 Serious Mental Illness
 Serious Emotional Disturbance
 Complex Trauma

Two or More of the following: Visit Here


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
Name of referred Organization