Healthy Alliance Screening Assessment
This screening tool is used to support you with your health goals. Your response will not affect your benefits and services and should NOT be completed if you filled one out within the last 6 months.
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth:
*
-
Month
-
Day
Year
Date
Sex:
*
Please Select
Male
Female
Phone Number
*
Please enter a valid phone number.
Is this a cell phone or home phone?
*
Please Select
Cell Phone
Home Phone
Can you receive text on this phone:
*
Please Select
Yes
No
Medicare Identification Number (CIN)
If you have Medicare please enter you ID number above.
Please Indicate if you have helath insurance:
*
Please Select
Yes, I have insurance
No, I'm uninsured
Screening and Targeted Health Questions:
In the last 12 months, did you ever eat less than you felt you should because there was not enough money for food?
*
Yes, I plan to self resolve
Yes, I agree to a referral
No
2. In the last 12 months, has your utility company shut off your service for not paying your bills?
*
Yes, I plan to self resolve
Yes, I agree to a referral
No
3. Are you worried that in the next 2 months you may not have stable housing?
*
Yes, I plan to self resolve
Yes, I agree to a referral for services
No
4. Do problems getting childcare make it difficult for you to work or study? (If No children, please select N/A)
*
Yes, I plan to self resolve
Yes, I agree to a referral for services
No
N/A
5. In the last 12 months, have you needed to see a doctor, but could not because of cost?
*
Yes, I plan to self resolve
Yes, I agree to a referral for services
No
6. In the last 12 monts, have you ever had to go without health care becasue you did not have a way to get there?
*
Yes, I plan to self resolve
Yes, I agree to a referral for services
No
7. Do you ever need help reading hospital materials?
*
Yes, I plan to self resolve
Yes, I agree to a referral for services
No
8. Are you afraid you might be hurt in your apartment building or house?
*
Yes, I plan to self resolve
Yes, I agree to a referral for services
No
9. Have you seen a primary care provider in the last 12 months?
*
Yes, I plan to self resolve
Yes, I agree to a referral for services
No
10. Are you currently enrolled in a Medicaid Managed Care Plan with an "Active" status?
*
Yes
No
Type option 4
11. Do you require assistance accessing your prescriptions?
*
Yes, I plan to self resolve
Yes, I agree to a referral for services
No
Name of person who completed Questions:
*
First and Last Name
Date Completed:
*
-
Month
-
Day
Year
Date
Signature
*
Clear
Maggy Pharmacy Inc 1165 Route 374 Dannemora, NY 12929
Submit
Should be Empty: