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 


Please Enter Your Contact Information

Please Enter the Information of the Person Needing Services

Place a checkmark in the box if any of the following are true:

Paper Referral

Eligibility Category Information

Care Management Needs - Check all that apply and specify detail

Risk and Safety Concerns - Check All the Apply


Optionally, Attach a File