ICS Health Home Member Referral Form

The ICS Health Home is not a place. It is a program run by disability experts who help members get what they need to stay as healthy and independent as possible—in their home. In order to be eligible, an individual must have Medicaid and reside in the Bronx, Brooklyn, Manhattan, or Queens. To refer someone, please complete the form below and provide as many details as possible. Note all information submitted is encrypted to ensure protection of personal information.

If you would first like to learn more about the program, including its various benefits and services, please call 646.653.6230.

Note, a "*" symbol indicates the field is mandatory.

Consumer Information

First Name*

Last Name*

Primary Phone #*

Phone Type

Additional phone #

Phone Type

Address

Suite/Apt/Box

City

State

Zip

Date of Birth*

Age:

Gender*

Email Address

Primary Language*

Social Security #*

Medicaid #*

Medicare (if applicable)

Currently enrolled in a Medicaid Managed Long-Term Care (MLTC) plan?*

How did you learn about ICS Health Home?*

Family/Caregiver/Additional Contact Information (If Applicable)

Alternate Contact Name

Referrer Information (If Applicable)

Referrer First Name

Referrer Last Name

Primary Care Physician(PCP)

Name of PCP or health care facility:

Phone #

Comments

Please add any information you feel would be helpful (e.g., diagnoses, reason for referral, additional alternate contacts, etc.) and/or attach any supporting documents:

File Attachment(Max Size: ___; Types: Excel, Word, PDF, and TIFF Accepted)

Confirmation

To receive a confirmation for this referral, please provide your email address below. Due to HIPAA regulations, confirmation email will only include the date and time received and will not stipulate any personal information, such as referral name.

By clicking "Submit Form," it is my intent to refer this consumer to the ICS Health Home, and I have the appropriate authority to make the referral. I attest that the information is truthful and the consumer is aware of this referral. Submission of this information will result in Independence Care System contacting the individuals named in the form. Submit Form