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 Sex* -Select-MaleFemaleNo Answer Preferred 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. Submit