HOP Pre-screening

HOP Pre-screening

Due to the ongoing impacts of Hurricane Helene, HOP enrollments are paused. HOP enrollments are scheduled to begin again on Monday, October 28th. 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 CareI am the parent/guardian of Individual on Medicaid Managed CareCommunity Health Worker funded by Impact HealthOther
Which CHW organization?*

Caja SolidariaCentro Unido Latino AmericanoMountain Community Health PartnershipOperation GatewaySafe ShelterUnited Way of Rutherford CountyUNETEYMCA of WNCOther
Name of Parent/Guardian completing the form*

First NameLast Name
Name of CHW completing the form*

First NameLast Name
Name of Medicaid Managed Care Recipient*

First NameLast Name
County of Residence*
Other County
Medicaid Managed Care Plan Provider*
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

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
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?*

YesNo
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:
How did you hear of HOP?*

My care manager, social worker or insurance planCommunity health workerMy healthcare professional (doctor/nurse/physician)An organization/non-profit where I receive servicesA family member, friend, acquaintance or co-workerThrough school or daycareA flyer, brochure, or social mediaBillboard, radio or TV advertisementInternet searchOther
For CHW Worker: What other types of services have you connected this client with, outside of HOP? (check all that apply)

HealthcareHousingFoodTransportationViolence interventionLegalJob/WorkChildcareEducationOther
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*

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