Referral to Family Health Home Visiting

Dakota County Referral to Family Health Home Visiting Fax to 651-554-6130 or Email referral to [email protected]

Referral Source/Phone: Date:

Name of clients/fami Race/ ly members Birth Date Sex Referral Reason Ethnicity being referred First name: M Initial Last name: M PG, EDD: Postpartum F

Low Birth Premature Other: M PG, EDD: Postpartum F

Low Birth Premature Other: Foster Parent/ Guardian Name (if not the parent): Family Address: cell Alternate Phone: cell home home Phone: Client may be contacted by: Phone

Text E-mail Cell Phone Carrier We may leave Recorded Client / family aware of referral: message Y N Message with person English Interpreter Needed First time parent: Language: Spanish Y Y N Other: N

DCPHD-FH-1053 (1/18) Comments:

Intake staff MA/Minnes processing PMAP Private Insurance ota Care only: PMAP # UCare yes no BCBS Carrier: ID: PMI #

HealthPartners PMAP # UCare Error: yes no Reference BCBS Carrier: source not ID: Client found PMI # Insurance HealthPartners Informatio PMAP # UCare Error: n yes no Reference BCBS Carrier: source not ID: found PMI # HealthPartners PMAP # UCare Error: yes no Reference BCBS Carrier: source not ID: found PMI # HealthPartners Open to other Dakota yes no E&EA PH SS:(worker name) County Programs Mother Primary/Re AP Par PP2WK PP3MO MVS-I MVS-C Other: ason Child Primary/Re GRW ASTH BDIS EHDI LEAD FAP MVS-I MVS-C Other: ason NSC NSC FH Referral Family Rapid Response Destinatio Health Child Passenger Safety WSC WSC FH n: Family Rapid Health Response

PH Doc #: Intake PHN: Pending:

DCPHD-FH-1053 (1/18)