Skip to main content

Book Appointment

Home
Home
Care Coordination
Care Coordination Referral

Care Coordination Referral

Refer a patient to our Care Coordination or Health Home program

Referral Details

Urgency Level*

Referral Source*

Referrer Name*

Referrer Phone*

Referrer Email

Referrer Fax

Patient Demographics

First Name*

Last Name*

Date of Birth*

Gender

Primary Language

Phone*

Email

Address

Address*

City*

State

Zip Code*

Living Situation

Insurance / Medicaid

Medicaid CIN*

Example: AB12345C

Insurance Plan Name*

Member ID

Chronic Conditions (select all that apply)

Substance Abuse DisorderAsthmaBMI > 25Cardiovascular DiseaseDiabetesHeart DiseaseHIV / AIDSHypertensionMental Health ConditionChronic Kidney DiseaseChronic Liver DiseaseCOPDSickle Cell AnemiaStrokeTraumatic Brain InjuryOther

Health Home Appropriateness Criteria (select all that apply)

Frequent ER visits (3+ in 12 months)Hospitalized 2+ times in 12 monthsSkilled nursing or rehab facility stayMultiple chronic conditions (2+)Prescribed 6+ medicationsLack of social support / housing instabilityBehavioral health diagnosisSubstance use disorderDifficulty managing medicationsMissed or inconsistent appointments

Additional Notes

I confirm the patient has consented to this referral and to sharing their medical information.

Questions About Care Coordination?

Contact us to learn more about eligibility and our programs.

If you are experiencing a medical emergency, please call 911.

Comprehensive healthcare for the communities we serve.

1550 University Avenue, Bronx, NY 10452

Quick Links

Urgent Care
Primary Care
Specialty Care
House Calls
Locations

Patient Resources

Book Appointment
Accepted Health Plans
Medical Records
Pay My Bill
Patient Portal

Connect With Us

About Essen
Careers
News
Contact Us

© 2026 Essen Health Care. All Rights Reserved.

Privacy Policy Terms & Conditions Accessibility