ACCRA – Clinic@Home powered by HealtheMed

Accra Client Lead Form

I am a Care Manager (QP) for the following program* -Select-PCAIHSHome Care / Skilled Nurse245DFMS

First Name*Last Name*Phone*Email *

ACCRA Client

Client First Name *Last Name * Contact Phone
Email Waiver Categories *-Select-CADIDDACCACBIEWOther PMI Address/Street Address Address Line 2CityState/Region/ProvincePostal / Zip Code Date of Birth(MM-dd-yyyy)

Responsible Party/Guardian

First NameLast Name Phone Number
Email

Waiver Case Manager or Health Plan- Waiver Case Coordinator 

(Contact person who approves services on Medicaid Waiver)

First Name Last NameCounty Phone Number Email Organization

Reason:

Please explain in 3 – 4 sentences why you feel HealtheMed’s Clinic@Home would benefit your client. Did you speak to your Client already to introduce the service? Please select one option*-Select-I prefer to Contact the Case Manager first to introduce this service.The ACCRA Program lead will contact the Case Manager to obtain their referral on
Thank you for the referral information.
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