Community Care HUB Referral Form - 1889 Jefferson Center for Population Health

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):

Health Insurance ID Number (if applicable)

Primary Care Provider (if known)

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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