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Healthfirst long term care
Referral Form

Healthfirst CompleteCare (MAP) & Senior Health Partners (MLTC) Referral Form

Please fill in all requested information below

To contact us or to receive more information call 1-866-585-9280, Monday to Friday, 8am-8pm, Saturday, 10am-6:30pm.

Referring Provider

* First Name Required

* Last Name Required

* This field is required

* This field is required

* Please enter a valid email address

* Please enter a valid phone number

* Please enter a valid address

* Please enter a valid address

* Please enter a valid city

* Please enter your five-digit zip code

* Required Field

Client Information

Referral For *

* First Name Required

* Last Name Required

* Birth Date Required

* Please enter a valid email address

* Please enter a valid phone number

* Please enter a valid address

* Please enter a valid address

* Please enter a valid city

* Please enter your five-digit zip code

Client Emergency Contact Information

* First Name Required

* Last Name Required

* This field is required

* Please enter a valid phone number

* Please enter a valid phone number

* Required Field

Client Information

Does the client have Medicaid?
* If no Medicaid, does client want to apply?

* This field is required

Client Medicare Information

Does the client have Medicare?

* This field is required

Are you part of any Healthfirst Medicare plan?

Referral Source Attestation

I, * , attest that the client was informed of the referral and agrees to receive more information about the MAP and/or MLTC program.

TO ALL LICENSED HOME CARE AGENCIES:

If this client is presently receiving services from a Certified Home Health Care Agency (CHHA), the Licensed Home Care Agency attests that the CHHA has been notified that this client is being referred to Healthfirst CompleteCare (HMO SNP) or Senior Health Partners (SHP) regarding potential enrollment.

All information will be kept confidential. Thank you for your Referral!
Disclaimer Information:

Healthfirst Medicare Plan is an HMO plan with a Medicare contract and a contract with the New York Medicaid program. Enrollment in Healthfirst Medicare Plan depends on contract renewal. The Healthfirst CompleteCare (HMO SNP) Medicaid Advantage Plus is a program for people who have both Medicare and Medicaid. Eligible beneficiaries can enroll at any time. Contact Healthfirst CompleteCare (HMO SNP) for additional information.

Senior Health Partners is a managed long term care plan affiliated with Healthfirst.

* Required Field