The code block below illustrates how one might use # and // as comments in your logic and calculations.

# Text can be put here to explain what the logic/calculation does and why.
if ([field1] = '1' and [field2] > 7,

	// This comment can explain what the next line does.
	[score] * [factor],

	// Return '0' if the condition is False.
	0
)

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Required format:

Division of Developmental Disabilities (DD) Health Home Referral

The Division of DD has implemented a DD Health Home for individuals statewide served through DD, who have a qualifying chronic health condition, have or at risk of developing another chronic condition, and are eligible for Division of DD services.

Individuals covered by Medicaid are eligible to be served by a DD Health Home if they have a chronic condition of Intellectual and/or Developmental Disability; and have or be at risk of developing one of the following conditions:

Diabetes;
Asthma;
Cardiovascular disease or hypertension;
Chronic Obstructive Pulmonary Disease (COPD);
Overweight (Body Mass Index (BMI)>25);
Dementia;
Dependent on a ventilator;
Tobacco use;
Diagnosis of Autism Spectrum Disorder;
One of the Fatal Five Plus Conditions: Pulmonary Aspiration, Bowel Obstruction, Gastroesophageal Reflux Disease (GERD), Seizures, Sepsis, Dehydration;
Using the Health Risk Screening Tool that identifies potential risk for individuals with a Healthcare Level of 3 or greater.

Form Instructions: Individuals, guardians, formal supports, community partners, Support Coordinators, and other State agencies may also refer an individual for DD Health Home eligibility determination by completing this form.

Note: This form prompts the Division to determine eligibility for DD Health Home services. If needed to obtain additional information, the Division may contact the Individual and/or Legal Guardian.

* Required Fields

Full name: *
Date of birth: *		SSN (last 4 digits: *
DMHID:		Medicaid DCN:

Street:
City: *
State:
Zip Code: *
County: *

Phone Number: *		Addtl Phone:
E-Mail Address:

Individual's Intellectual / Developmental Disability: *

Individual's Qualifying Chronic Health Condition(s): *

Individual's Address - CIty:

* must provide value

Individual's Address - Zip Code:

* must provide value

Please upload record(s) related to the individual's chronic health condition(s) are required for DD Health Home eligibility determination.

Clinical Record(s) Indicating Diagnosis from Licensed Practitioner

(ie: Hospital Report, History & Physical Exam, Neurological, etc.)

* must provide value

Upload file

Are you the parent of the individual?

* must provide value

Yes No

reset

Does the individual have a responsible person?
(legal guardianship, power of attorney / durable power of attorney, authorized representative)

* must provide value

Yes No

reset

Full name: *
Relation/Affiliation:
Legal Responsibility:
Special Communication Needs:

Street: *
City: *
State: *
Zip Code: *

Phone Number: *
E-Mail Address:

Records related to legal responsibility and decision making authority are required.

Upload relevant records below:

* must provide value

Upload file

Responsible Person's Address - CIty:

* must provide value

Responsible Person's - Zip Code:

* must provide value

Full name: *

Relation/Affilication:

Street:
City:
State:
Zip Code:

Phone Number:
E-Mail Address:

Referrer's mailing address - city:

Referrer's mailing address - zip code:

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