Community Health Worker (CHW)
Recommendation Form

All fields required unless otherwise specified.

Member Information

Member Name This field is required Required Please enter text only

SFHP ID Number11-digit SFHP Member ID number This field is required Required Please enter your valid 11-digit Member ID

Date of BirthEnter Month, Day, and Year ex. “08/08/1998” This field is required Invalid date format.

Member Phone NumberPlease provide at least one phone number

Cell Phone Number This field is required Please enter a valid phone number

Home Phone Number This field is required Please enter a valid phone number

Member's Preferred Language This field is required

Member's PCP/Clinic This field is required

Member Mailing Address This field is required

Is the member aware of the recommendation?

Yes

CHW Recommendation Information

Referral Date Invalid date format.

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

Licensed Referring Provider Information

Name Please enter text only

Title

NPI #

Provider Phone Number Please enter a valid provider phone number

Facility/Clinic

Address

Provider Email
Please enter valid e-mail address.

Is the referring provider the same as the supervising provider?

Yes

^*If “No”, please provide supervising provider information:

Supervising Provider Name This field is required Please enter text only

Title This field is required

NPI # This field is required

Provider Phone Number This field is required Please enter a valid provider phone number

Facility/Clinic
This field is required

Address
This field is required

Provider Email
Please enter valid e-mail address. 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
Invalid date format.

Anticipated CHW end date
Invalid date format.

CHW recommendation request sent to (name of CHW provider)

Has the member received prior CHW services?

Yes

^*If Yes, please add:

Which CHW services provider? This field is required

Dates of service This field is required Invalid date format.

Purpose
This field is required

Community Health Worker (CHW) Recommendation Form

Member Information

CHW Recommendation Information

Licensed Referring Provider Information

Recommendation Details

Community Health Worker (CHW)
Recommendation Form