Get Countycare - Health Risk Screening Form Health Risk Screening Form

Filling out the Countycare - Health Risk Screening Form online is an important step in ensuring that your health needs are properly addressed. This guide will provide you with clear and detailed instructions on how to complete the form efficiently and effectively.

Follow the steps to complete the form online

1. Press the ‘Get Form’ button to obtain the form and open it in your designated editor.
2. Begin by entering your last name and Medicaid ID number in the provided fields. These identifiers are crucial for processing your information accurately.
3. Input your member date of birth in the specified format (mmddyyyy). This ensures that the records are kept up-to-date and match your profile.
4. Enter the name of the person answering the questions, followed by the member's first name and height measurements in feet and inches. Specify if you are completing the form for yourself, or if you are a parent or guardian.
5. Answer the question regarding your primary care provider (PCP). Specify if you know who your PCP is and provide their name and phone number if applicable.
6. Indicate when you last saw your PCP and whether you have an upcoming appointment, entering the scheduled date if applicable.
7. Continue to the next section, answering questions about any behavioral health providers you see. You should indicate if you have visited one, their name, phone number, and the date of your last visit.
8. Review and answer questions related to hospital admissions, emergency room visits, and any current pregnancy status if applicable.
9. Provide information about any current medical conditions and mental health statuses by checking the appropriate boxes on the form.
10. Indicate if you are working with a service coordinator or case manager, providing their agency, name, and contact number.
11. Finally, answer additional questions concerning your general well-being, including any thoughts of self-harm and your interest in receiving support.
12. When you have completed all sections, ensure you save changes made to the form. You can then download, print, or share the form as required.

Complete your Countycare - Health Risk Screening Form online today to ensure your health needs are met.