Individuals and agencies may use this form to connect with a Community Health Worker.

To visit the Health Care Access Now website go to healthcareaccessnow.org

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1. Priority

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2. Best day to call client (Required.)

Date

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3. Agency Information (if self-referral, type N/A in the fields) (Required.)

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4. Client Contact Information (Required.)

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5. Client Personal Information (Required.)

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6. Medicaid Member ID #

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7. Medicaid Insurance Plan Name (Required.)

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8. Medicaid Plan ID #

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9. Do you have any other health insurance plan?

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10. Client Needs (Required.)

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11. If client has a current health condition - describe:

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12. Other Needs

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13. Number of children in home (Required.)

0 5 10
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i We adjusted the number you entered based on the slider’s scale.

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14. If child has a health condition, please explain. (If none, please use N/A in the field below). (Required.)

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15. What is your (client's) gender? (Required.)

T