Eligibility Questionnaire

Enrollment in a Health Home requires that the patient meet certain eligibility criteria, such as being Medicaid-eligible and experiencing a qualifying diagnosis.

Please fill out the below questionnaire to the best of your ability for the patient in your care. If the individual is eligible for CCF assistance, you will be prompted to fill out and submit a referral application form.


Basic Eligibility:

Does the child/youth currently have active Medicaid coverage?

Eligibility Type: (If ICD10 code available, please provide)

Does the patient reside in New York City, on Long Island or in Westchester County?

Apropriateness Criteria (Check all that apply for patient)