Home · GRHHN referral

To qualify for Health Home Care Management services individuals must have active Medicaid as well as chronic health conditions and care management needs. Please know the individual’s Medicaid CIN (example: AB12345C), chronic diagnoses, care management needs, and contact information prior to completing this form. Including these and other applicable items assists care managers as they contact and begin work with individuals. If you have questions reach out to the GRHHN Intake Team at 585-350-1400 or by sending a secure email to grhhnintake@flpps.org.

Consent *

By checking this box, I agree I have read the Consent Form and give my permission to GRHHN to use and disclose my records for the purpose of coordinating the delivery of services to me and related health care operations OR I am completing this referral on behalf of a client or family member and I agree I have read the Consent Form and obtained verbal consent from the referred person and/or their legal guardian and they have given permission to GRHHN to use and disclose their records for the purpose of coordinating the delivery of services to them and related health care operations. Click here to download the consent form.

Please Enter Your Contact Information

First Name

Last Name

Title

Referrer Organization

Choose one record and click Select to continue

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Phone

Please include area code (Example: 000-000-0000)

Phone Type

Please enter an email address or select "No Email". Completion of this field is a requirement for submission.

No EMail

Please Enter the Information of the Person Needing Services

Referral First Name

Referral Last Name

Referral DOB

Please enter DOB in the format shown above. Be sure to include slashes to seperate Month/Date/Year.

Referral CIN

Referral Gender

Enter Male, Female or X for nonbinary, agender, or gender non-conforming.

Referral Homeless

Please Select " Referral Homeless" if applicable. Otherwise complete address fields below.

Referral Address 1

Referral Address 2

Referral Address City

Referral Address State

Referral Address Zip

Referral County

Referral Phone

Please include area code (Example: 000-000-0000)

Referral Alternate Contact

Referral Current Providers

Referral Language

Requested Care Management Agency

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Paper Referral

Check if you are attaching a paper referral. If so, skip to the “Attach a File” section at the bottom of this paper. If you are not attaching a paper referral please complete all the sections below.

Eligibility Category Information

Please select a minimum of one "Tier1" or two "Tier 2" diagnosis for this section. In the corresponding text box, the associated diagnosis must be entered. Completion of these fields are a requirement for submission.

Tier 1 - Complex Trauma (Only applicable for individuals under 21 referred to the Children’s Health Home Program. Please attach completed Complex Trauma Exposure Form if selecting.)
Complex Trauma Exposure Form.

Tier 1 - HIV/AIDS

Tier 1 - Sickle Cell

Tier 1 - Serious Mental Illness (Adult) or Serious Emotional Disturbance (Child)
View Serious Emotional Disturbance Definition.

Tier 2 - Mental Health Condition

Tier 2 - Substance Abuse Disorder

Tier 2 - Asthma

Tier 2 - BMI > 25

Tier 2 - Diabetes Type 1

Tier 2 - Diabetes Type 2

Tier 2 - Heart Disease

Tier 2 - Other Chronic Health Condition(s)

Care Management Needs - Check all that apply and specify detail

Please select a minimum of one care management need. A description must be entered in the corresponding box. Completion of these fields are a requirement for submission.

Risk and Safety Concerns - Check All the Apply

Please select a minimum of one risk and safety concern. A description of the concern must be entered in the corresponding box. Completion of these fields are a requirement for submission.

Suicidal ideation

Homicidal ideation

Active substance abuse

History of suicide attempts

History of violence

Unsafe living environment

Other Risk

None identified

Narrative

Optionally, Attach a File

Please attach any supporting documents. Refrain from including chart notes.

Please ensure that all fields with an asterisk (*) are complete before clicking submit.