Care Management at Montefiore

Health Home Enrollment and Referral

BAHN
CMO Cares

To refer a patient to the BAHN Health Home, Montefiore Care Management, please provide the information requested below and press the submit button at the bottom of the page. The form will be submitted to the BAHN portal and a BAHN representative will acknowledge receipt of the referral form.

The BAHN Health Home can help you and your patients who have multiple comorbidities; have frequent avoidable ED visits or hospitalizations; are experiencing functional decline; have behavioral health issues or financial issues that affect their compliance with treatment; need help with medication compliance or affording medication; or who could benefit from end of life or advanced illness planning.

For a full list of conditions considered for placement, please see our Health Home Chronic Conditions List

If you have any questions or prefer to speak to a BAHN Health Home representative, call the BAHN Central line at 1-855-680-2273.

Client Information*




Referral Source Information


Clinical Eligibility Criteria*
Or Patients Having Two of the Following
Risk Assessment*