Date: / / HealthChoice To: Attention: LOCAL HEALTH SERVICES Address: City/State/Zip: REQUEST FORM Phone: Client Information Client Name: Race: African-American/Black Address: Alaskan Native American Native City/State/Zip: Asian Native Hawaiian Phone: Pacific Islander White County: More than one race Unknown Caregiver/Emergency Contact: DOB: / / SS#: - - Sex: M F Hispanic: Y N Relationship: MA#: Phone: Private Ins.: No Yes Martial Status: Single Married Unknown If Interpreter is needed specific language: FOLLOW-UP FOR: (Check all that apply) RELATED TO: (Check all that apply) Child under 2 years of age Missed appointments: #missed Child 2 21 years of age Adherence to plan of care – Child with special health care needs Immunization delay Pregnant EDD: ____ / ____ /____ Preventable hospitalization Adults with disability(mental, physical, or Transportation developmental) Other: Substance use care needed Homeless (at-risk) Diagnosis: Comments: MCO: Date Received: / / Document Outreach: Unable to Locate # Letter(s) # Phone Call(s) Contact Date: / / # Face to Face Advised Refused Comments: Contact Person: Provider Name: Phone: Provider Phone: Fax: Local Health Department (County) Date Received: / / Document Outreach: No Action (returned) # Letter(s) # Phone Call(s) Reason for return: # Face to Face Disposition: Contact Complete: Date: / / Contact Person: Unable to Locate: Date: / / Contact Phone: Referred to: Date: / / Comments:
Date: / / To: Attention: Address: City/State/Zip: Phone: HealthChoice LOCAL HEALTH SERVICES REQUEST FORM Client Information Client Name: Address: City/State/Zip: Phone: County: DOB: / / SS#: - - Sex: M F Hispanic: Y N MA#: Private Ins.: No Yes Martial Status: Single Married Unknown If Interpreter is needed specific language: Race: African-American/Black Alaskan Native American Native Asian Native Hawaiian Pacific Islander White More than one race Unknown Caregiver/Emergency Contact: Relationship: Phone: FOLLOW-UP FOR: (Check all that apply) Child under 2 years of age Child 2 – 21 years of age Child with special health care needs Pregnant EDD: ____ / ____ /____ Adults with disability(mental, physical, or developmental) Substance use care needed Homeless (at-risk) RELATED TO: (Check all that apply) Missed appointments: #missed Adherence to plan of care Immunization delay Preventable hospitalization Transportation Other: Diagnosis: Comments: MCO: Date Received: / / Document Outreach: # Letter(s) # Phone Call(s) # Face to Face Unable to Locate Contact Date: / / Advised Refused Comments: Contact Person: Phone: Fax: Provider Name: Provider Phone: Local Health Department (County) Date Received: / / Document Outreach: # Letter(s) # Phone Call(s) # Face to Face No Action (returned) Reason for return: Disposition: Contact Complete: Date: / / Unable to Locate: Date: / / Referred to: Date: / / Contact Person: Contact Phone: Comments: