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BAHN Form

BAHN Health Home Referral Form

Instructions: Please complete this form for all health home referrals to BAHN. Please submit to BAHNCentral@montefiore.org. For assistance or further questions, please call our referral line (855) 680-2273

Sex (as listed on the Medicaid Card):
 

Referral Source Contact Information

Referrals < 21 Years of Age

Did the Member provide verbal or written consent to be referred to Health Home?
 
Please indicate the individual from whom you have obtained consent (medical consenter) to refer the child to the Health Home program:
 

Medical Consenter for Referrals

Health Home Medicaid Eligibility

Is the Member Medicaid Fee for Service?
 
If No, please select Medicaid Managed Care Organization below:
     
   

Health Home Clinical Eligibility Criteria

One of the following single qualifying conditions:
 
Serious Mental Illness(SMI) Adult Only (SMI is determined by both a diagnosis of mental illness and functional impairment(s))





Serious Emotional Disturbance (SED) Children Only (SED is determined by both a diagnosis of mental illness and functional limitations due to emotional disturbance over the past 12 months on a continuous or intermittent basis)



















(Please include required complex trauma screenings forms) Children Only
https://www.health.ny.gov/health_care/medicaid/program/medicaid_health_homes/hh_children/complex_trauma.htm
Or Two or more chronic conditions
Physical Health Conditions
     
     
       
 
Developmental/Intellectual Disabilities
         
     
Alcohol and Substance-Related Conditions
     
     
 
Mental Health Conditions
   
   
     
   
     
   
     
     
 
Risk Assessment

Referrals are eligible for Health Home services if at least one of the following risk factors apply








Social Determinants of Health Assessment

Please identify any unmet health-related social needs that impact the referred individual