HOP Pre-screening
Thank you for your interest in the Healthy Opportunities Pilot (HOP). If you have Medicaid and live in Western North Carolina, you may be eligible for services to support your well-being. To see if you qualify, please answer the prescreening questions below. Your care manager will contact you if you are eligible for HOP.
Who is completing this form?
*
Individual on Medicaid Managed Care
I am the parent/guardian of Individual on Medicaid Managed Care
Community Health Worker funded by Impact Health
Other
Which CHW organization?
*
Caja Solidaria
Centro Unido Latino Americano
Mountain Community Health Partnership
Operation Gateway
Safe Shelter
United Way of Rutherford County
UNETE
YMCA of WNC
Other
Name of Parent/Guardian completing the form
*
First Name
Last Name
Name of CHW completing the form
*
First Name
Last Name
Name of Medicaid Managed Care Recipient
*
First Name
Last Name
County of Residence
*
Please Select
Avery
Buncombe
Burke
Cherokee
Clay
Graham
Haywood
Henderson
Jackson
Macon
Madison
McDowell
Mitchell
Polk
Rutherford
Swain
Transylvania
Yancey
Other County and not eligible
Other County
Medicaid Managed Care Plan Provider
*
Please Select
AmeriHealth Caritas
Healthy Blue
Partners Health Management
United HealthCare (UHC)
Vaya Health
WellCare
Other and not eligible for HOP
Select your Prepaid Health Plan (PHP)/Insurance Company for Medicaid Managed Care
Medicaid ID number from Insurance/PHP Card
Member ID is 9 digits and a letter; Member ID is not required, but will reduce processing delays
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
Please enter for the Medicaid Managed Care recipient
Best Phone Number to reach you
*
Please enter a valid phone number.
Is it ok to leave a message?
*
Yes
No
You have indicated it is unsafe to leave a message, please share what days of the week and times that it is safe for a phone call to be received about this application
*
Is there a best time to reach you?
Please indicate your preferred Language, if other than English:
Please Select
Spanish
Ukrainian
Russian
Mandarin
Other
How did you hear of HOP?
*
My care manager, social worker or insurance plan
Community health worker
My healthcare professional (doctor/nurse/physician)
An organization/non-profit where I receive services
A family member, friend, acquaintance or co-worker
Through school or daycare
A flyer, brochure, or social media
Billboard, radio or TV advertisement
Internet search
Other
For CHW Worker: What other types of services have you connected this client with, outside of HOP? (check all that apply)
Healthcare
Housing
Food
Transportation
Violence intervention
Legal
Job/Work
Childcare
Education
Other
In order to complete the pre-screening process, you must provide consent to receive services through NCCARE360.
By consenting, you agree to share information with a Network of health and social service partners powered by Unite Us software. This Network is made up of entities and individuals who are directly involved in your care or payment of care. Your personal information may be shared securely on the Network in accordance with privacy laws to connect you with services. This consent covers all information shared by you or by anyone that has the right to share information on your behalf and is relevant to the recipient’s involvement in your care or payment for your care. You can always limit the information you provide on the Network by requesting to have it removed. To understand how your information may be used and kept safe on the Network, please see uniteus.com/privacy. If you no longer want your information shared on the Network, you can email consent@uniteus.com or ask any Network partner.
Please sign in the box below to provide your consent to the above statement to receive services
*
Submit
Should be Empty: