Submit a Referral : How To Help : Florida Community Health Worker Coalition

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Community Health Worker/Provider Information

If you are a Community Health Worker or Provider, enter your information below.

Name

First Name

Last Name

Phone Number

04xa2docflji

Referring Entity

Medical Home

PCP Name

Client Information

Enter information of person in need of services below.

Client Name

First Name *

Middle

Last Name *

DOB

Age

Gender

Race/Ethnicity

Address

Country

Address Line 1 *

City *

State/Province *

Postal Code *

Phone Number

Emergency Contact Name

First Name *

Last Name *

Emergency Contact Phone

Health Condition(s)

Health Related Social Needs

Select all health related social assistance services being requested.

Check All That Apply

Other(s)

Healthcare Access Needs

Select all health care access assistance services being requested.

Check All That Apply

Other(s)

Healthcare Utilization

Select how the person requesting assistance has used the following healthcare options.

Check All That Apply

Preventable Emergency Department Use
Frequent Emergency Department Use
Readmissions to Hospital
Inappropriate Emergency Department Use
Dental Emergency Department Use
Additional Comments (specify below)

Additional Comments

Health Insurance Coverage

Select health insurance type of person requesting assistance.

Check All That Apply

Insurance Coverage
Prescription Coverage
Uninsured
Other (specify below)

Other

Additional Notes

Additional Attachments

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Confidentiality Notice: This form and and attachments are for the sole use of the identified recipient(s) and may contain confidential and privileged information. Any unauthorized review, use, disclosure, forwarding, or distribution is prohibited. If you are not the intended recipient, please contact the sender by phone and delete this message.

Submit a Referral

Community Health Worker/Provider Information

Client Information

Health Related Social Needs

Healthcare Access Needs

Healthcare Utilization

Health Insurance Coverage

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