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New York State’s Health Home eligibility criteria is as follows:

Medicaid eligible/active Medicaid and two (2) or more chronic conditions; or one (1) single qualifying condition of either HIV/AIDS or a Serious Mental Illness (SMI)

All fields marked with an (*) are required.
 

ELIGIBILITY INFORMATION

Do you have Medicaid?(*)

Please select one.

What MCO do you currently have?(*)
Please select one.

Do you have two (2) or more chronic conditions?(*)

Please select one.

Choose Condition #1(*)
Please select one.

Choose Condition #2(*)
Please select one.

Do you have one (1) single qualifying condition?(*)

Please select one.

PATIENT INFORMATION

First Name(*)
Please enter your first name.

Last Name(*)
Please enter your last name.

Gender(*)

Please select one.

Date of Birth(*)
Please enter your date of birth.

Address(*)
Please enter your address.

City(*)
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State(*)
Please enter your state.

Zip Code(*)
Please enter your zip code.

Phone Number(*)
Please enter your phone number.

Email(*)
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CIN
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Religion
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Primary Language(*)
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Other Primary Language(*)
Please enter your other primary language.

Secondary Language
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Other Secondary Language
Please enter your other primary language.

Emergency Contact Name
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Emergency Contact Phone
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REFERRAL INFORMATION

Source of Lead(*)
Please select one.

Referral First Name(*)
Please enter the referral first name.

Referral Last Name(*)
Please enter the referral last name.

Referral Phone Number(*)
Please enter the referral phone number.

If referral is urgent or you wish to share other information with GBUAHN, please explain

ADDITIONAL INFORMATION

Enter your full name to represent your signature(*)
Please enter your full name to represent your signature.

I Agree(*)
Please check the box to agree with GBUAHN contacting you.

Questions / Comments
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Human Verify
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By submitting this form, I understand and agree to be contacted by GBUAHN.