CORE Referral Form Page MHA of Rochester CORE Referral Form Please complete the form below. If you have any questions, please contact Program Manager, Tammy DeMarle, 585-325-3145 x 129. Date MM slash DD slash YYYY Name* First Last Gender Race/Ethnicity Phone #Primary Language Spoken Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Participant Health Care InformationManaged Care Organization* Excellus Fidelis Molina MVP United Select One Tier 1 Tier 2 Policy # or Plan ID BH Primary Diagnosis (ICD-10 F Code)* MCO Contact Name (First, Last) MCO Contact Phone #MCO Contact Email Medicaid CIN Referral SourceName (First, Last) Agency Name Agency Phone #Email Agency Fax #Any Known Safety Concerns? If none, list "N/A"Examples: History of violence, weapons in the home, dogs, sex offender, general concerns, etc. If none, list "N/A"Any Identified Service Restrictions Surrounding Participant Availability? If none, list "N/A"MHA of Rochester ServicesPlease select the service(s) you are interested in. HCBS Habilitation CORE Psychosocial Rehabilitation PSR - Employment PSR - Education Empowerment Services (Peer Supports) Family Support & Training Documents HCBS requires the Plan of Care, MCO Letter of Service Determination, Tier Level, and ICD-10 F Code be included with the referral form. Please upload the files in the space below. Drop files here or Select files Max. file size: 300 MB. CAPTCHA