Eligibility Enrollment

New York State’s Health Home eligibility criteria is as follows:

Medicaid eligible/active Medicaid and two (2) or more chronic conditions; or one (1) single qualifying condition of either HIV/AIDS or a Serious Mental Illness (SMI)

"*" indicates required fields

1Personal Information

2Contact Information

3Referral Information

Do you have Medicaid?**

Yes

What health plan do you currently have?*

Do you have two (2) or more chronic conditions?**

Yes

Note: New York State’s Health Home eligibility criteria is as follows: Medicaid eligible/active Medicaid and two (2) or more chronic conditions such as Asthma, Diabetes, High Blood Pressure, High Cholesterol or Arthritis; or one (1) single qualifying condition of either HIV/AIDS, Sickle Cell or a Serious Mental Illness (SMI)

First name*

Last name*

Date of birth*

Gender*

Email*

Phone*

Religion*

Address*

Street address Address line 2 City State / province / region ZIP / postal code Country

CIN*

Eligibility enrollment

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