Health Home Form

Health Home

Health Home Referrals

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)

Do You Have Medicaid? *

Yes

What MCO do you currently have?

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

Yes

First Name *

Last Name *

Date of Birth *

Gender

Religion

Email *

Phone *

Address *

Address Line 2

City *

Postal Zip Code

Country *

CIN *

Primary language *

Secondary language

Emergency Contact Name

Emergency Contact Phone

Source of Lead *

Referral Name *

Referral Phone

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

I Agree *

I understand that CINQCARE will be contacting me

Enter your full name to represent your signature

Questions / Comments

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Health Home

Health Home Referrals

Health Home eligibility

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NEW YORK CITY

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WASHINGTON, D.C.

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Health Home

Health Home Referrals

Health Home eligibility

Contact Us BUFFALO

CORPORATE OFFICE NEW YORK CITY

CORPORATE HQ WASHINGTON, D.C.

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Contact Info

Keep In Touch

Recent Shots

Contact Us
BUFFALO

CORPORATE OFFICE
NEW YORK CITY

CORPORATE HQ
WASHINGTON, D.C.