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




 Age:



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Family/Caregiver/Additional Contact Information (If Applicable)


 

Referrer Information (If Applicable)


Primary Care Physician(PCP)


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