Member Information	HealthPartners SNBC Care Coordinator and HRA information
Date: Member Name: DOB: Address: Phone #: Ok to text? Yes No Email: Preferred method of contact: (call, text, email, other) Legal Guardian or Conservator name and contact information, or n/a: Member’s primary language:	Name: Phone #: email: Type of HRA (initial/annual/change of condition): Initial Annual Change of Condition Other If change of condition or other, describe in detail:
Medical Care and Information
PCP Name: PCP Phone#: PCC Name / Address: PCC a health-care home? Yes No Member’s diagnosis:

Service Request Information
Is member open to a waiver? Yes No If yes, indicate: CAC CADI BI DD	Describe formal services currently in place, if any:	Describe member’s informal or quasi-formal supports, if any:
Service(s) Requested:	Person Requesting Services: If not member, describe person’s relationship to member:	Source(s) of information about this need / request:
Why is this service being requested?	Risk(s) mitigated by services requested:	What alternatives to formal services have been explored?
Does SNBC CC agree the member needs the services requested and that there are no feasible alternatives to formal services? Yes No If no, describe in detail:	Is the member at risk of losing access to the community, isolation, or a significant reduction in independence without formal services? Yes No	Describe how the requested services will help prevent or delay institutionalization.

Health Risk Assessment Summary Information
Date of last HRA: Face-to-face HRA? Yes No	HRA Attached: Yes No	If not attached, describe member’s ADL and IADL status:
Describe any assistance devices used:	Describe assistance, if any, member receives with ADLs or IADLs:	Describe any behaviors member demonstrates: Describe any assistance member receives to manage behaviors:
Describe the member’s strengths:
Care Coordination Supervisor Approves this Referral Yes No If no, do not submit referral to County, use other resource avenues to meet the member’s needs.