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