Ottawa Pathways to Better Health

Referring Agency

Type of Referral Agency 211 Referral Agency Ambulance Service Area Agency on Aging Community Health Worker Community Mental Health County Human Service Office Emergency Department Health Plan Home Health Agency Primary Care Practice Self-Referred Specialty Care Practice

Phone Number

Fax Number

Email

Best way to reach? Phone Fax Email

Date of Birth (Important, if known!)

First Name

Last Name

City

State

Zip

County Allegan Muskegon Ottawa

Phone Number

Email

Best way to reach? Phone Fax Email

Does this client need an interpreter: Yes No

Gender Male Female

Due Date (if pregnant)

Ethnicity Hispanic or Latino Non-Hispanic or Latino

Primary Spoken Language English Arabic Bosnian Burmese Chinese Farsi French Hindi Hmong Nepali Spanish Somali Swahili Vietnamese Other

Race (check all that apply) White or European American
Black or African American
Asian or Asian American
American Indian or Alaska Native
Native Hawaiian & Other Pacific Islander
Other

Insurance Type (check all that apply) Medicaid or Healthy Michigan Plan
Medicare
Commercial
None
Other

Primary Doctor Name

Name of Practice

Primary Doctor Phone Number

# of ED visits in the past 12 months

# of hospital admissions in the past 12 months

Other