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Community Care HUB Referral Form
Community Care HUB Referral Form
Center for Population Health
2022-01-31T19:53:50+00:00
Referral Consent
*
Individual has given consent to share the below information with the Community Care HUB for the purpose of enrollment into the care coordination program.
Referral Eligibility (check one)
*
Pregnant; lives in Cambria or Somerset county; receiving or eligible for Medical Assistance
Pregnant; lives in Cambria or Somerset county; diagnosed with Gestational Diabetes
Family member of Greater Johnstown Elementary School student (attendance barriers, academic barriers, connection to community resources)
Family Member of Somerset Area School District student (attendance barriers, academic barriers, connection to community resources)
Parenting – 0-18 months (*HUB Pre-approval required)
Referral Name (Primary Caregiver, if child)
First Name
*
Last Name
*
Referral Address
Referral Phone #
*
If Greater Johnstown School District, please list each child's name, grade level, and needs below:
If Somerset Area School District, please list each child's name, grade level, and needs below:
Referral Date of Birth (if known):
Referral Insurance Status
*
Uninsured
Medicaid
Medicare
Commercial
Other
Unknown
Health Insurance ID Number (if applicable)
Primary Care Provider (if known)
Referral needs help with connections to (check all that apply)
*
Developmental referral
Education
Employment
Family Planning
Food Security
Housing
Health insurance
Healthcare (Physical, Behavioral, SUD, Oral)
Medication Assistance
Social Services
Transportation
Other
Notes
List any known chronic conditions of referral
If pregnant, what is the participant's estimated due date?
If pregnant, who is the OB Provider?
Person Completing this Form
First Name
Last Name
Referring Provider/Agency (if not self-referral)
Phone # of Person Completing this Form
*
Email of Person Completing this Form
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