Get Ny Ccfhh Referral Facesheet Form 2016-2026

Completing the NY CCFHH Referral Facesheet Form is essential for referrals to the CCF Health Home. This guide provides step-by-step instructions to assist you in accurately filling out the form online.

Follow the steps to successfully complete the facesheet form online.

1. Click ‘Get Form’ button to access the NY CCFHH Referral Facesheet Form and open it for editing.
2. Enter today's date in the designated field at the top of the form to indicate when the referral is being made.
3. Fill in the child's name, including last name, first name, and middle initial. Be sure to include any aliases or nicknames they may be known by.
4. Provide the child's date of birth in the specified format to ensure accurate identification.
5. Complete the child's current address, including city and ZIP code, to facilitate communication and locate the child when necessary.
6. Select the child's gender by checking the appropriate box: Male, Female, Transgender Male, or Transgender Female.
7. Input the Medicaid/CIN number associated with the child for proper insurance processing.
8. Indicate the county of residence by selecting from options including NYC, Westchester, Nassau, and Suffolk.
9. State the child's language preference other than English, if known, to ensure effective communication.
10. Provide the name of the MCO plan, if applicable, and attach a copy of the Medicaid card if available.
11. In the 'Permission to Refer' section, confirm that consent has been obtained for the referral and specify the individual who provided this consent.
12. Complete the fields regarding the medical consenter's name, relationship to the child, email, and address, along with the date permission was obtained.
13. Enter the guardian's phone numbers and indicate if the child is currently in foster care by checking yes, no, or unknown.
14. Address the family or residential information by indicating if any family member is enrolled in another Health Home and, if so, provide their name and relationship to the child.
15. Fill in the care management section with the health home name and agency, and select eligibility type according to the criteria provided.
16. Document any pertinent eligibility conditions, including conditions like Serious Emotional Disturbance or chronic conditions, by listing them in the required fields.
17. Complete the referral source section by selecting the appropriate option and including relevant organization information.
18. Attach any optional documents as listed, recognizing that lack of documentation should not impede the referral process except for complex trauma cases.
19. Once all sections have been accurately filled out, save the changes to the form. You can then download or print the completed form, or share it as required.

Begin your referral process online by filling out the NY CCFHH Referral Facesheet Form today.