Enhanced Services Program Eligibility Questionnaire
Harvest House Buffalo, INC.
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Date *
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Name of Coordinating Organization
Name/Number of your Case Manager
Name *
Date of Birth
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Zip Code *
Medicaid CIN number *
Preferred Language
Do you give us consent to contact you to determine eligibility screening for Medicaid Enhanced Services? *
How would you prefer to be contacted? Check all that apply.
Preferred contacted information *
Are you enrolled in a Medicaid Managed Care Health Plan? *
Are you under 18 years of age?
Clear selection
Are you Pregnant, Post-Partum and/or Nursing?
Clear selection
Do you have any Chronic Health Conditions or Mental Illnesses?
Clear selection
Do you have any Intellectual & Developmental Disabilities(IDDs)?
Clear selection
Do you have a steady place to live?
Clear selection
Are you at risk of homelessness and/or being evicted?
Clear selection
In your current home have you received shut off notices for utilities?
Clear selection
Does your current home need repairs that are affecting your health?
Yes or No.    If yes, please explain.
Are you worried your food will run out and you won't have money/resources to buy more?
Clear selection
In the last 90 days have you been released from Incarceration, admitted, discharged, or transferred from a Detox/Residential placement?
Clear selection
Do you have significant changes in family, income, job status, and benefits?
Clear selection
Do you need help with transportation for education, employment interviews, grocery shopping, and court appointments regarding housing? (Excluding medical appointments.)
Clear selection
Do you visit the Emergency Room frequently?
Yes or No.   If yes please explain.
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