Contact & Personal Information

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Contact & Personal Information
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Social Needs Screening — Accountable Health Communities (AHC) HRSN Tool
Screening Consent

We use this screening to understand needs our clients may have that could interfere with good health. We may share your answers with healthcare providers, your health plan, and social service organizations to determine if you qualify for free non-medical services that may help.

  • You may choose not to answer this survey, but we can only check for services if you respond.
  • You may choose to be screened later and may still be eligible for extra services.
  • None of this will affect your ongoing Medicaid eligibility.
Screening consent is required.
Referral Network Consent

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I consent to sharing my information with a network of health and social service providers to connect me with services. Click here for more information about how your information may be used.

Referral network consent is required.
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Your information is kept confidential and used only to coordinate services.