Enrollment (BH) | WellCare NY Concierge Care

Member Name*

First Last

Mobile Number*

If you are enrolling a child and parent/guardian under Medically Fragile Children, please indicate the parent/guardian's mobile number below.

Group ID*

Plan ID*

Member ID*

Suffix*

County*

Please Select Preferred Language*

English
Spanish

Which team did the GOMO referral initiate from:

New Enrollment
Health Home
Unable to Reach/Lost to Contact
High Risk (HIV, DSNP, SUD etc)
Engaged
HARP TOC

Date Risk Assessment completed*

Member acuity (IPRO+Risk)*

High
Moderate
Low

Natural Supports

Yes
No

Condition Type:

Member may select up to 2 primary conditions and up to 2 secondary conditions.

Select up to 2 primary conditions

General Health and Wellness
Asthma
Behavioral Health
Congestive Heart Failure
COPD
Diabetes
At Risk Pregnancy
Substance Use Disorder SUD

Select up to 2 secondary conditions (optional)

Must be different from primary conditions.

Asthma
Behavioral Health
Congestive Heart Failure
COPD
Diabetes
At Risk Pregnancy
Substance Use Disorder SUD

Due Date*

Please indicate the expected due date for the at-risk pregnancy

Is the member pregnant with a substance dependence?*

Yes
No

Please check any substance dependencies that apply*

Opioid
Other

What "other" substance is the member dependent on?*

Add a Caregiver, Partner, or Loved One

Does the member want to sign up a loved one, partner or caregiver who shares in their care to receive the same messaging?*

Yes
No

Caregiver Name*

First Last

Caregiver Mobile Number*

Caregiver Authorization*

I authorize a one-time communication to my caregiver to confirm their enrollment in the program. By checking this box, I also provide electronic consent for my caregiver to receive my Personal Health Information via text messages to the mobile number provided.

Privacy Policy*

We’re just about done signing you up. Once I complete your enrollment, you will receive a confirmation text message containing a link that will take you to the program’s terms and conditions, as well as some HIPAA information for you to read through. With that being said, I do need you to confirm that you understand that text, like email, is not considered a secure technology and that the messages you receive may indicate the nature of your condition. However, beyond the general nature of your condition, this program does not send Protected Health Information (PHI) via text. Do you accept?

I agree to the privacy policy.

Electronic Consent*

The Telephone Consumer Protection Act generally requires us to obtain consent before contacting members on their mobile phones. By enrolling in this program, you are granting consent to Fidelis Care and/or GoMo Health to contact you via text message to the number you are enrolling with. Text messages may include health care information related to your healthcare services. Please note that depending on your mobile phone service plan, message and data rates may apply to your mobile provider. You also confirm that you are the wireless subscriber or owner of the mobile number provided and have authority to provide consent. You may opt-out at any time by replying STOP or STOPALL to 52046.

I have verbally completed the enrollment form and provide electronic consent to enroll. I grant permission to Fidelis Care and/or its GoMo Health to contact my cell phone via text messages.

Enrolled by*

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Enrolled by Value

Enrolled by*

First Last

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IsChronic

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DaysCalc

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OptinDate

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PrimaryPregSubstance

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PrimaryPregSubstanceES

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SecondaryPregSubstance

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SecondaryPregSubstanceES

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PrimaryPregNoAbuse

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PrimaryPregNoAbuseES

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SecondaryPregNoAbuse

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SecondaryPregNoAbuseES

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StartPoint

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PrimaryPregChat

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