Community Health Worker (CHW)
Recommendation Form
All fields required unless otherwise specified.
Member Information
Member Name
This field is required
Required
SFHP ID Number
11-digit SFHP Member ID number
This field is required
Required
Date of Birth
Enter Month, Day, and Year ex. “08/08/1998”
This field is required
Member Phone Number
Please provide at least one phone number
Cell Phone Number
This field is required
Home Phone Number
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Member's Preferred Language
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Member's PCP/Clinic
This field is required
Member Mailing Address
This field is required
Is the member aware of the recommendation?
Yes
No
CHW Recommendation Information
Referral Date
Referring Entity/Source
Licensed Provider: MD, RN, LVN, Psychologist, LCSW, MFT, Pharmacist
Hospital
Outpatient Clinic
Local Health Jurisdiction (LHJ)
Community-Based Organization (CBO)
Medical Group
*
If you selected Medical Group, please add:
Medical Group Name
This field is required
Does the member’s Medical Group have access to CHW services?
Yes
No
Licensed Referring Provider Information
Name
Title
NPI #
Provider Phone Number
Facility/Clinic
Address
Provider Email
Is the referring provider the same as the supervising provider?
Yes
No
*
If “No”, please provide supervising provider information:
Supervising Provider Name
This field is required
Title
This field is required
NPI #
This field is required
Provider Phone Number
This field is required
Facility/Clinic
This field is required
Address
This field is required
Provider Email
This field is required
Recommendation Details
Member meets eligibility criteria for CHW services based on the presence of one or more of the following:
Diagnosis of one or more chronic health (including behavioral health) conditions, or a suspected mental disorder or substance use disorder that has not yet been diagnosed.
Presence of medical indicators of rising risk of chronic disease (e.g., elevated blood pressure, elevated blood glucose levels, elevated blood lead levels or childhood lead exposure, etc.) that indicate risk but do not yet warrant diagnosis of a chronic condition.
Any stressful life event presented via the Adverse Childhood Events screening.
Presence of known risk factors, including domestic or intimate partner violence, tobacco use, excessive alcohol use, and/or drug misuse.
Results of a SDOH screening indicating unmet health-related social needs, such as housing or food insecurity.
One or more visits to a hospital emergency department (ED) within the previous six months.
One or more hospital inpatient stays, including stays at a psychiatric facility, within the previous six months, or being at risk of institutionalization.
One or more stays at a detox facility within the previous year.
Two or more missed medical appointments within the previous six months.
Member expressed need for support in health system navigation or resource coordination services.
Need for recommended preventive services, including updated immunizations, annual dental visit, and well childcare visits for children.
CHW violence prevention services are available to Members who meet any of the following circumstances:
The Member has been violently injured as a result of community violence.
The Member is at significant risk of experiencing violent injury as a result of community violence.
The Member has experienced chronic exposure to community violence.
Number of CHW visits requested (more than 12 will require a submission for prior authorization):
Anticipated CHW start date
Anticipated CHW end date
CHW recommendation request sent to (name of CHW provider)
Has the member received prior CHW services?
Yes
No
*
If Yes, please add:
Which CHW services provider?
This field is required
Dates of service
This field is required
Purpose
This field is required
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