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Contact
Who We Are
What We Do
Community Care HUB
Community Health Workers
COVID-19 Task Force
Food Access
Housing Access
Resources/Data
News
Annual Reports
Newsletters
Events
Community Care HUB Referral Form
Community Care HUB Referral Form
Center for Population Health
2022-01-31T19:53:50+00:00
Referral Consent
*
Individual has given consent to share the below information with the Community Care HUB for the purpose of enrollment into the care coordination program.
Referral Eligibility (check one)
*
Pregnant; lives in Cambria or Somerset county; receiving or eligible for Medical Assistance
Pregnant; lives in Cambria or Somerset county; diagnosed with Gestational Diabetes
Parenting (0-18 Months); Lives in Cambria or Somerset County; eligible for or receiving Medical Assistance
Parent or Guardian of Greater Johnstown Elementary School student (attendance barriers, academic barriers, connection to community resources)
Parent or Guardian of Somerset Area School District student (attendance barriers, academic barriers, connection to community resources)
Magellan Health Referrals
If Magellan Health
*
Twin Lakes inpatient
Twin Lakes outpatient
Family Medical Center (FMC)
Not Magellan Referral
Referral Name (Primary Caregiver, if child)
First Name
*
Last Name
*
Referral Date of Birth (if known):
Referral Address
Referral Phone #
*
If School District, please list each child's name, grade level, and needs below:
Referral Insurance Status
*
Uninsured
Medicare
Commercial
Unknown
Other
Medicaid
(If Medicaid, choose 1 of the 4 options below)
Highmark Wholecare
UPMC 4 U
Health Partners
AmeriHealth
Magellan
Health Insurance ID Number (if applicable)
Referral needs help with connections to (check all that apply)
*
Developmental referral
Education
Employment
Family Planning
Food Security
Housing
Health insurance
Healthcare (Physical, Behavioral, SUD, Oral)
Medication Assistance
Social Services
Transportation
Other
Notes
If pregnant, who is the OB Provider and what is the participant's estimated due date?
Person Completing this Form
First Name
Last Name
Name of CHW who Referred
Referring Provider/Agency (if not self-referral)
Phone # of Person Completing this Form
*
Email of Person Completing this Form
Submit
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