Please take a few minutes to fill out the questions below. This information will help us identify any health care services you may require. If you have any questions, call us at 1-833-ASK-NLHP (833-275-6547) (TTY: 711).
First Name:

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* 1. First Name:

Last Name:

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* 2. Last Name:

Medicaid ID #:

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* 3. Medicaid ID #:

Date Of Birth

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* 4. Date Of Birth

MM/DD/YYYY
Age

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* 5. Age

Mailing Address

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* 6. Mailing Address

Relationship to Member:

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* 7. Relationship to Member:

What is your preferred language:

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* 8. What is your preferred language:

Gender/Sex:

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* 9. Gender/Sex:

What is the best time of day and phone number to reach you?

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* 10. What is the best time of day and phone number to reach you?

Who can we contact in case of an emergency? Please list their name and contact information:

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* 11. Who can we contact in case of an emergency? Please list their name and contact information:

Current Height (Required)

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* 12. Current Height (Required)

Current Weight (Required)

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* 13. Current Weight (Required)

Are you allergic to peanuts and/or bee stings?

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* 14. Are you allergic to peanuts and/or bee stings?

Do you have an Integrated Health Home (IHH), Primary Care Provider (PCP), or Women's Healthcare Provider (WHCP)? 

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* 15. Do you have an Integrated Health Home (IHH), Primary Care Provider (PCP), or Women's Healthcare Provider (WHCP)? 

Enter your PCP Name: 

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* 16. Enter your PCP Name: 

Enter your PCP Phone Number:

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* 17. Enter your PCP Phone Number:

When was the last time you visited a doctor or a clinic?

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* 18. When was the last time you visited a doctor or a clinic?

Do you have an appointment scheduled with your PCP? 

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* 19. Do you have an appointment scheduled with your PCP? 

Have you had any of the following exams in the last 12 months?

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* 20. Have you had any of the following exams in the last 12 months?

Do you see more than one doctor?

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* 21. Do you see more than one doctor?

How would you describe your health? (Required)

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* 22. How would you describe your health? (Required)

Have you been admitted to a hospital in the past six (6) months? (Required)

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* 23. Have you been admitted to a hospital in the past six (6) months? (Required)

If yes, how many times?

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* 24. If yes, how many times?

Have you been to the emergency room (ER) more than once in the last 6 months?

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* 25. Have you been to the emergency room (ER) more than once in the last 6 months?

If yes, please check one of the boxes below:

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* 26. If yes, please check one of the boxes below:

Are you being treated for any of the following? Check all that apply:

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* 27. Are you being treated for any of the following? Check all that apply:

Have you been prescribed any medications?

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* 28. Have you been prescribed any medications?

Do you have any difficulty taking your medications as prescribed?

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* 29. Do you have any difficulty taking your medications as prescribed?

Do you need any medical equipment or supplies?

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* 30. Do you need any medical equipment or supplies?

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