CareHub Intake Form

Serving Pathways to Better Health & Managing Asthma Through Case Management in Homes (MATCH Program)
Ingham Health Plan Corp's 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 adultAn adult with an appointed legal guardianA child (age 0-17)
Is the client aware of this referral?

YesNo
Person Completing Form
Referring Agency
Type of Referral Agency*
Phone Number

Area CodePhone Number
Fax Number

Area CodePhone Number
Email
example@example.com
Best way to reach?

PhoneFaxEmail
Client Information
First Name*
Last Name*
Date of Birth*

MonthDayYear
Date
Gender

MaleFemaleNon-binaryPrefer not to answer
Due Date (if pregnant)

MonthDayYear
Address

Street Address

Street Address Line 2

CityState

Zip Code
County*
Phone Number

Area CodePhone Number
Email
Best way to reach?

PhoneTextEmail
Primary Spoken Language
Does this client need an interpreter?

YesNo
Insurance & Health Information
Insurance Type (check all that apply)

Medicaid/Healthy Michigan PlanMedicareIngham Health PlanCommercialNone
Medicaid/HMP Plan Name
(For Pathways referral: if not McLaren, member should contact health plan's customer service # on back of insurance card for available programs and support.)
Medicaid #
Date Medicaid Confirmed

MonthDayYear
Date
Medicare Plan Name
Medicare #
Date Medicare confirmed

MonthDayYear
Date
IHP HPMS #
Date IHP Confirmed

MonthDayYear
Date
Plan Name & Member #
Primary Doctor Name (or Pediatrician if referral is for a child)
Primary Doctor Phone Number

Area CodePhone Number
# 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 AbuseAnxietyArthritisAsthmaCOPDDepressionDiabetesHigh Blood PressureHyperlipidemiaStrokeTobaccoUnsure
Legal Guardian Information
First Name
Last Name
Date of Birth

MonthDayYear
Gender

MaleFemaleNon-binaryPrefer not to answer
Phone Number

Area CodePhone Number
E-mail
Reason(s) for Referral
Adult Main Reason for Referral*
Child Main Reason for Referral*
Other Reasons for Adult Referral (if applicable, check all that apply)

Abuse/NeglectAccess to Behavioral Health Services (includes mental health/substance abuse)Access to Community ResourcesAccess to Medical ProviderChronic Conditions ManagementDisabilityEnvironmental Risk (mold, lead, pests, etc.)Inappropriate ED useMedication ConcernsNeeds Healthcare Coverage (Medicaid/IHP)Pregnancy or Postpartum SupportRecent Hospitalization/Readmission Risk
Other Reasons for Child Referral (if applicable, check all that apply)

Abuse/NeglectAccess to Community ResourcesAccess to Medical ProviderAsthmaAt Risk of Dismissal From Medical HomeAccess to Behavioral Health Services (includes mental health/substance abuse)Development Delay (speech, language, hearing, vision, etc.)DisabilityEnvironmental risk (mold, lead, pests, etc.)First ChildInappropriate ED useMissed Appointment(s)Need Appointment RemindersNeed Immunizations Up To DateNeed Transportation For Medical AppointmentsNeeds Healthcare Coverage (Medicaid/IHP)Parent EducationTeen Parent
Access to Community Resources for*

ClothingCounselingEmploymentFinancialFoodHousingInsuranceLegalTransportation
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.

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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) 394-4590

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

Insurance & Health Information

Legal Guardian Information

Reason(s) for Referral

Any Additional Information