Medi-Cal Member Recommendation for Community Health Worker/Promotora Services

Medi-Cal Member Recommendation for Promotora/CHW Benefit or Asthma Services (APS or AR)

Visión y Compromiso provides health education and navigation services to help beneficiaries get the care they need.
Referring Party*
Who is filling out this referral?
Department*
Referral Type*
Person Submitting Referral*

First NameLast Name
Submitter Email*
Email of the person submitting this referral
Anthem Blue CrossCalOptimaCalVivaHealth NetHPSJIEHPKern Health SystemsLA CAREMolinaWhite Memorial Universal ClinicsOther
Member Name*

First NameLast Name
Member Phone Number: *
Please enter a valid phone number.Format: (000) 000-0000.
Member Emergency Phone Number (other):
Please enter a valid phone number.Format: (000) 000-0000.
Member Date of Birth

MonthDayYear
Date
Member ID#/CIN#:
Health NetCalOptimaMolinaIEHPCalVivaAnthemKern HealthOther
Notes
Please include any additional information that will help us with this referral such as key diagnosis, the services you are requesting for the member Asthma Prevention Services, Asthma Remediation, CHW Services
Community Health Worker BenefitsAsthma Prevention Services (APS)Asthma Remediation (AR)
KernLos AngelesMaderaOrangeRiversideSacramentoSan BernardinoSan JoaquinStanislausTulareOther
Member Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Member's Preferred Language*
Diagnosis of one or more chronic health conditionsBehavioral Health condition or mental health disorder undiagnosed.Any stressful life events based on ACES screeningPresence of any known risk factors such as: domestic violence, partner violence and substance use.SDoH identified with self-assessmentOne or more Emergency Room visits in the past 6 monthsOne or more Hospital inpatient stays in past 6 monthsOne or more stays at a detox facility within the previous year.Two or more missed medical appointments within past 6 months.Member expressed need for support in health system navigation or resource coordination services.Need for preventive health care servicesMember received a score of 19 or lower on the Asthma Control Test.Member experienced asthma related emergency department visit, hospitalization or urgent care asthma related visits in the past 12 months.
Licensed Practitioner Name:*

First NameLast Name
Licensed Practitioner NPI#*
PhysicianClinical Nurse Specialist (CNS)DentistLicensed Clinical Social Worker (LCSW)Licensed Educational Psychologist (LEP)Licensed Marriage & Family Therapist (LMFT)Licensed MidwifeLicensed Professional Clinical Counselor (LPCC)Licensed Vocational Nurse (LVN)Nurse MidwifeNurse Practitioner (NP)PharmacistPhysician Assistant (PA)PodiatristRegistered Nurse (RN)PsychologistPublic Health Nurse (PHN)Registered Dental Hygienist (RDH)Other
I Attest
I attest
I attest
Protected Health Information:
The information requested above is Protected Health Information (PHI) and is the minimum necessary to execute outreach and delivery of patient services. Please understand that as a link in the "Chain of Trust", all PHI will remain confidential as mandated by the Treatment, Payments, and Healthcare Operation Laws mandated by HIPAA.
Licensed Provider Signature: *

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Medi-Cal Member Recommendation for Promotora/CHW Benefit or Asthma Services (APS or AR)