ACCRA – Clinic@Home powered by HealtheMed ACCRA Staff I am a Care Manager (QP) for the following program * -Select- PCA IHS Home Care / Skilled Nurse 245d FMS Other First Name * Last Name * Phone * Email * ACCRA Client Client First Name * Last Name * Contact Phone Email Waiver Categories * -Select- CADI DD AC CAC BI EW Other PMI Address /Street Address Address Line 2 City State/Region/Province Postal / Zip Code Date of Birth (MM-dd-yyyy) Responsible Party/Guardian First Name Last Name Responsible Party Phone Number Responsible Party Email Waiver Case Manager or Health Plan – Care Coordinator (Contact person who approves services on Medicaid Waiver) First Name * Last name * County Phone Email Organization (County, Contracting Agency or Health Plan) Reason 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 this 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 Lead. Submit