CareHub Intake Form

Serving Pathways to Better Health & Managing Asthma Through Case Management in Homes (MATCH Program)
CareHub serves as a vehicle to connect those in need - including infants, children, parents, families, caregivers and adults with chronic health conditions - to health and social service resources and programs to help better their lives and improve health.
Referral Source Information
Referral is for

An adult An adult with an appointed legal guardian A child (age 0-17)
Is the client aware of this referral?

Yes No
Person Completing Form
Referring Agency
Type of Referral Agency *
Phone Number

- Area Code Phone Number
Fax Number

- Area Code Phone Number
Email
example@example.com
Best way to reach?

Phone Fax Email
Client Information
First Name *
Last Name *
Date of Birth *

/ Month / Day Year
Date
Gender

Male Female
Due Date (if pregnant)

- Month - Day Year
Address
City
State
USPS Zip Code & County Finder
Zip Code *
County *
Phone Number

- Area Code Phone Number
Email
Best way to reach?

Phone Text Email
Race (check all that apply)

White or European American Black or African American Asian or Asian American American Indian or Alaska Native Native Hawaiian & Other Pacific Islander
Ethnicity

Hispanic or Latino Non-Hispanic or Latino
Primary Spoken Language
Does this client need an interpreter?

Yes No
Insurance Type (check all that apply)

Medicaid or Healthy Michigan Plan Medicare Medicare Advantage Ingham Health Plan Commercial None
Medicaid or Healthy Michigan Plan Name
Medicaid #
Date Medicaid Confirmed

- Month - Day Year
Date
Medicare Plan Name
Medicare #
Date Medicare confirmed

- Month - Day Year
Date
IHP HPMS #
Date IHP Confirmed

- Month - Day Year
Date
Primary Doctor Name (or Pediatrician if referral is for a child)
Primary Doctor Phone Number

- Area Code Phone Number
Name of Practice
# of ED visits in the past 12 months
# of hospital admissions in the past 12 months.
Chronic Health Conditions (check all that apply)

Addiction/Substance Abuse Anxiety Arthritis Asthma COPD Depression Diabetes High Blood Pressure Hyperlipidemia Stroke Tobacco Unsure
Legal Guardian Information
First Name
Last Name
Date of Birth

- Month - Day Year
Gender

Male Female
Phone Number

- Area Code Phone Number
E-mail
Reason(s) for Referral
Adult Main Reason for Referral *
Child Main Reason for Referral *
Other Reasons for Adult Referral

Abuse/Neglect Access to Behavioral Health Services (includes mental health/substance abuse) Access to Community Resources Access to Medical Provider Chronic Conditions Management Disability Environmental Risk (mold, lead, pests, etc.) Inappropriate ED use Medication Concerns Needs Medicaid Coverage Pregnancy or Postpartum Support Recent Hospitalization/Readmission Risk
Other Reasons for Child Referral

Abuse/Neglect Access to Community Resources Access to Medical Provider Asthma At Risk of Dismissal From Medical Home Access to Behavioral Health Services (includes mental health/substance abuse) Development Delay (speech, language, hearing, vision, etc.) Disability Environmental risk (mold, lead, pests, etc.) First Child Inappropriate ED use Missed Appointment(s) Need Appointment Reminders Need Immunizations Up To Date Need Transportation For Medical Appointments Needs Medicaid Coverage New Patient Intro To CHAP Parent Education Teen Parent
Access to Community Resources for *

Clothing Counseling Employment Financial Food Housing Insurance Legal Transportation
Any Additional Information
Please provide any additional information regarding the reason for this referral that may be helpful in determining eligibility into our programs. Please explain any concerns you may have checked off.

0/990
Attach any additional information

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A Division of Ingham Health Plan Corporation

P.O. Box 30125 I Lansing, MI 48909 I P: (866) 291-8691 I F: (517) 394-4549

www.ihpmi.org/carehub
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Serving Pathways to Better Health & Managing Asthma Through Case Management in Homes (MATCH Program)

Referral Source Information

Client Information

Legal Guardian Information

Reason(s) for Referral

Any Additional Information