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REQUEST FOR SERVICES
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Please complete as much information as possible so we can make the best possible referrals for you.
Required fields (marked with *) must be completed before submitting or an error will result and all fields will be reset. Use only numbers, no commas, in Annual Income; all date fields must be formatted as MM/DD/YYYY.
Requester Information (for requests on behalf of someone else)
Requester Name:
Requester Phone:
Requester Phone
-
-
Requester Agency Name:
Requester Email Address:
Requester Phone Ext:
Information on person needing services
First Name of person needing services *:
Last Name of person needing services *:
Preferred Method of Contact *:
Select One
Email
Phone
Address 1:
Address 2:
City:
Select One
Adams Basin
Batavia
Bergen
Brighton
Brockport
Churchville
Clarkson
Clifton
East Rochester
Fairport
Greece
Hamlin
Henrietta
Hilton
Holley
Honeoye Falls
Industry
Irondequoit
Loehmanns Plaza
Macedon
Mendon
Mumford
North Chili
North Greece
Other
Palmyra
Panorama
Penfield
Pittsford
Ridgemont
Rochester
Rush
Scottsville
Spencerport
Victor
Webster
West Henrietta
West Rush
Westgate
Other City:
State:
Select One
AK
AL
AR
AS
AZ
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MH
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
PW
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
Zipcode:
Phone(Home):
Phone(Home)
-
-
Email Address:
Who told you about the program:
Select One
Bridges To Health
Health Care Provider - Anthony Jordan Health Center
Health Care Provider - Baycreek OBGYN/Midwifery
Health Care Provider - Brown Square Health Center
Health Care Provider - Canalside Family Medicine
Health Care Provider - Canandaigua Medical Group
Health Care Provider - Clinton Family Health Center
Health Care Provider - Compass Care of Rochester
Health Care Provider - East Ridge Family Medicine
Health Care Provider - Evelyn Brandon Health Center
Health Care Provider - Excellus
Health Care Provider - Genesee Health Service
Health Care Provider - Genesee Mental Health
Health Care Provider - Genesee Pediatric
Health Care Provider - Genesis House
Health Care Provider - Grace Family Medicine
Health Care Provider - Health Reach Program
Health Care Provider - Highland Community OBGYN
Health Care Provider - Highland Family Health Center
Health Care Provider - Highland Hospital (NOT community health)
Health Care Provider - Highland Perinatal Center
Health Care Provider - Highland Women`s Health
Health Care Provider - Hilton Health Care Center
Health Care Provider - Huther Doyle
Health Care Provider - Jefferson Family Medicine
Health Care Provider - Lake Effect OBGYN & Midwifery
Health Care Provider - Lifetime Care
Health Care Provider - Lifetime Health
Health Care Provider - Long Pond Pediatric
Health Care Provider - Maternal Fetal Medicine
Health Care Provider - Mt. Hope Family Center
Health Care Provider - North Ponds Family
Health Care Provider - Northridge Medical Group
Health Care Provider - Oak Orchard Community Health Center
Health Care Provider - Orchard St. Community Health Ctr.
Health Care Provider - Panorama Valley OBGYN
Health Care Provider - Park West Women`s Health
Health Care Provider - Parkway OBGYN
Health Care Provider - Parkway Pediatrics
Health Care Provider - Penfield OBGYN
Health Care Provider - Planned Parenthood
Health Care Provider - Rochester Adolescent Medicine Program
Health Care Provider - Rochester General Pediatrics Associates
Health Care Provider - Rochester Gynecologic & OBGYN Associates
Health Care Provider - Rochester Mental Health
Health Care Provider - RRH - Henrietta OBGYN
Health Care Provider - RRH - Women`s Center at Alexander Park
Health Care Provider - RRH - Women`s Center at Clinton
Health Care Provider - RRH - Women`s Center at Portland
Health Care Provider - Step By Step Rochester
Health Care Provider - Strong Hospital - Not elsewhere listed
Health Care Provider - Strong Ties
Health Care Provider - Strong Women`s Behavioral Health Services
Health Care Provider - Strong Women`s Health Practice
Health Care Provider - Threshold
Health Care Provider - Unity Behavioral Health
Health Care Provider - Unity Family Medicine - St. Bernard`s
Health Care Provider - Unity Hospital (NOT OB office)
Health Care Provider - Unity OBGYN - Brockport
Health Care Provider - Unity OBGYN - Clinton Crossing
Health Care Provider - Unity OBGYN - Erie Canal Park
Health Care Provider - Unity OBGYN - Park Ridge
Health Care Provider - Unity OBGYN - Parkway
Health Care Provider - Unity OBGYN - Ridgeway
Health Care Provider - Unity OBGYN - Titus Ave
Health Care Provider - Unity OBGYN - Wellshare
Health Care Provider - Unity OBGYN - West Main
Health Care Provider - Unity OBGYN @ St Mary`s
Health Care Provider - UR Medicine Midwifery
Health Care Provider - UR Medicine Specialty Care Clinic
Health Care Provider - UR Medicine Women`s Health Practice
Health Care Provider - URMC
Health Care Provider - Visiting Nurse Service
Health Care Provider - West Ridge Family Medicine
Health Care Provider - Women Gynecology & Childbirth Associates
Health Care Provider - Woodward Health Center
New Hope Family Services
Other - Accountable Health Partners
Other - ARC of Monroe Co
Other - Baby Love - MICHC
Other - Baby Love - other
Other - Baden Street Settlement House
Other - Berkshire Farms
Other - Bethany House
Other - Birthright of Rochester
Other - Birthright of Victor
Other - BOCES
Other - BreastFeeding Partnership
Other - Caring Choices Pregnancy Help Center
Other - Catholic Charities
Other - Catholic Family Center
Other - Center for Teen Empowerment
Other - Center for Youth Services
Other - Charles Settlement House
Other - Comienzo Sano
Other - Coordinated Care Services - TASA
Other - Early Intervention
Other - Easter Seals of NY
Other - Embracing Options
Other - Family Member
Other - Fidelis Care
Other - Friend
Other - Greece Schol District
Other - Head Start Program
Other - Healthy Baby Network
Other - Healthy Moms
Other - Healthy Start @ RGH
Other - Hillside - Alternatives for Indepentent Youth
Other - Hillside - In Home Diversion
Other - Hillside Children`s Center
Other - IBERO American Action League
Other - Lakeshore Community Church
Other - Learning Disability Associates
Other - Liberty Partnership Program
Other - Lifetime Assistance
Other - MC Dept of Public Health
Other - MCDHS - Child Protective
Other - MCDHS - Foster Care
Other - MCDHS-YOU
Other - Mercy Community Services
Other - Monroe County Correctional Services
Other - Monroe County Office of Probation
Other - Monroe County Teen Treatment Court
Other - Monroe County Vital Records
Other - Monroe County Youth and Family Services
Other - Monroe Plan
Other - MVP Health Care
Other - Nurse Family Partnership
Other - Parents as Teachers - Crestwood
Other - Puerto Rican Youth Development
Other - RESTORE Sexual Assault Services
Other - Rochester City School District
Other - Salvation Army
Other - Self Referral
Other - Sojourner House
Other - Southwest Area Neighborhood Association
Other - SPCC
Other - Teen Age Services Act
Other - Urban League of Rochester
Other - Villa of Hope
Other - Webster Central School District
Other - Wilson Commencement Park
Other - WIC
Other - Young Mothers Program
Other - Young Women`s College Prep Charter School
Other - Your Care Health Plan
Other - YWCA
Planned Parenthood
Issues/Needs:
Alcoholism/Substance Abuse
Baby items
Birth Preparation
Breastfeeding education
Case Management
Child care
Child development concerns
Child education
Child`s Health
Department of Human Services (financial support)
Disability
Domestic violence
Emergency/crisis child care
Foster placement or CPS history
GED/job training
Health Education
Home Assessment
Housing
Jobs
Lack of support/isolated
Late entry to care
Lead testing - child
Lead testing - maternal
Legal Assistance
Legal issues history
Medical concerns
Medical insurance
Mental Health - assessment
Mental Health - urgent/crisis assessment
Mental Health History
Missing pediatrician appointments
Missing prenatal doctor appointments
Other
Parenting skills
Pediatrician - hearing
Pediatrician - vision
Pre-natal Needs Assessment
Prenatal Education
Quitting Smoking
Recent losses
Safety of home
Survivors of Sexual Abuse
Transportation
WIC (food source for pregnant women and children)
Youth Development
Best Time to Contact:
Date of Birth:
Age:
Annual Income:
# in Household:
Health Ins Provider:
Select One
Aetna
BCO - Group Health
Blue Choice Option
Blue Choice Option-Lifetime Health
Blue Choice Options-Monroe Plan
Child Health Plus
Child Health Plus-Monroe Plan
Cigna
Essential Plan
Excellus Blue Cross Blue Shield
Family Health Plus
Family Health Plus-Monroe Plan
Fidelis
Healthy NY
Medicaid
Medicaid Pending
Medicare
MVP Health Care
MVP Option
MVP Option Child
MVP Option Family
None
Other
Tricare
United Health Care
Yourcare Health Plan, Inc
Homeless:
Homeless: Select One
No
Yes
Pregnant:
Select One
No
Not Applicable (Male)
Yes
If pregnant, Due Date:
# pregnancies including this one:
# previous live births:
Youngest Child's Age:
Select One
no children, but pregnant
no children, not pregnant
Less than 2 years old
2 to less than 3 years old
3 years old up to kindergarten age
kindergarten age or older
Comments:
Additional Information
If pregnant, have you begun care for your pregnancy:
If pregnant, have you begun care for your pregnancy: Select One
No
Yes
Date of First Pregnancy Care Visit:
Billing Prenatal Care Provider:
Provider Phone:
Provider Phone
-
-
Insurance Plan Contract # / Member #:
Issues or Concerns
Social:
Social: Select One or More
Education less than 12 Yrs.
Homeless
Husband / Partner Unemployed
Language barrier
Lives Alone
No Family Support
No Partner
No Phone
On Assistance greater than 1 year
Physical disability
Secondary Smoke in Residence
Transportation Problem
Unemployed (Patient)
Unstable Housing and Living Arrangement
Pregnancy:
Pregnancy: Select One or More
Abdominal Surgery
Age less than 16 or greater than 35 years
C-Section (Planned)
Cervical Incompetence
Fetal Abnormality
Gestational Diabetes
Less than 18 months between births
Miscarriage
Multiple Gestation
Placenta Abruptio
Placenta Previa
Pre-Eclampsia
Pregnancy Induced Hypertension
Preterm Labor
Tocolytics Used
Unplanned Pregnancy
Uterine Surgery
Medical:
Medical: Select One or More
Anemia
Asthma / COPD
Autoimmune Disorders
Dental Problem
Developmental Disability
Diabetes / Mellitus
DVT / Pulmonary Embolism
Heart / Cardiac Disease
High Blood Pressure / Hypertension
Hx. DES Exposure
Kidney Disorders
Overweight / Obese
Seizures
Thyroid Disorder
Tobacco Use
Under Weight
Confidential:
Confidential: Select One or More
Alcohol use / abuse
Children in foster care
Depression
Domestic violence
Drug use / abuse
Eating disorder
HIV / AIDS
Mental health diagnosis (Other)
Physical abuse
Risk of self harm
Sexual abuse
STDs
Consents
I attest that I am giving consent for myself or have obtained consent from the client to share client contact information with the Perinatal Network Outreach *:
I attest that I am giving consent for myself or have obtained consent from the client to share social and medical risk information with the Perinatal Network Outreach *:
I attest that I am giving consent for myself or have obtained consent from the client to share confidential health and other risk information that may include abuse, mental health, STD and HIV/AIDS-related information and treatment *:
Process Request:
The below disclosures will be part of the referral submissions to all receiving providers.This is to protect patient privacy and information.Each disclosure made with the patient's written consent must be accompanied by the following written statements
State of New York
OFFICE OF ALCOHOLISM AND SUBSTANCE ABUSE SERVICES
PROHIBITION ON REDISCLOSURE OF INFORMATION CONCERNING
SUBSTANCE ABUSE PATIENT
This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR part 2 and HIPAA). The federal rules prohibit you from making further disclosure of this information unless further disclosure
is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2 and/or HIPAA. A general authorization for the release of medical or other information is NOT sufficient for this purpose.
The federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.
For more information please visit, the link:
Information
TRS-1 (5/03) - For alcohol and substance abuse
State of New York
PROHIBITION ON REDISCLOSURE OF HIV RELATED INFORMATION
HIV related information may not be disclosed unless the client signs an approved HIV specific release form. Whenever HIV-related information is disclosed it must be accompanied by the following or similar statement:
"This information has been disclosed to you from confidential records which are protected by state law.
State law prohibits you from making any further disclosure of this information without the specific written consent of the person to whom it pertains, or as otherwise permitted by law.
Any unauthorized further disclosure in violation of state law may result in a fine or jail sentence or both. A general authorization for the release of medical or other information is NOT sufficient for further disclosure."
For more information please visit, the link:
Information