Essential Telehealth Services

Select the service(s) you need below. You can select more than one service.

You and up to 7 family members or friends can sign up. No COST. Family members DO NOT have to live in your home.

Essential Telehealth – New Patient Registration

Personal Information

First Name *

Middle Name / Initial

Last Name *

Date of Birth *

Sex/Gender *

Other:

Social Security Number (last 4 digits)

Full SSN (Optional)

Race / Ethnicity

Preferred Language

Contact Details Phone & Email

Phone Number *

Email Address *

County of Residence

Emergency Contact Name

Emergency Contact Phone

Emergency Contact Relationship

Home Address

Street Address *

ZIP Code *

City *

State *

Medicaid / Insurance Information

Managed Care Organization (MCO)

Secondary Policy / Member ID

Medicaid ID Number (Member ID)

State Medicaid Plan

Group Medicaid Plan

Group/Plan Number

Primary Insurance Type

Medicaid Both, Medicare Private Uninsured

Insurance Carrier Name

Subscriber Relationship to Insured

Perinatal Onboarding ILOS Eligibility & Enrollment

Required for Medicaid ILOS perinatal home-visiting eligibility. Fields marked * are required when a perinatal service is selected.

ON-1 — Eligibility & Referral

NOP & Risk Screening on File? *

Yes No

NOP Reference # *

NOP Date *

Overall Risk Level *

Referral Source *

CRIS / MCO Referral ID *

ILOS Qualifying Criteria (at least one recommended for eligibility)

High or Very High risk Moderate risk + lacks support system Domestic abuse risk

Consent to Home Visiting Referral

Yes No

ON-2 — Enrollment Anchors

Perinatal Stage * (auto-derived; override allowed)

Requested Enrollment / First Visit Date *

Visit Modality Confirmation (from Pregnancy section)

Reflects your Preferred Visit Modality selection above.

ON-3 — Rate-Routing Inputs

Home Visiting Model Type *

Geography Category (auto from county)

Resolved ILOS Rate Tier

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ON-4 — Family / Household

Household ID

Auto-generated on submission

Role in Household

Link Infant to Mother (Postpartum only) Enter the Member ID of the infant's registration record.

Referring Provider & Pharmacy

Referring Provider Name

Referring Provider NPI (10-digit)

Preferred Pharmacy Name

Pharmacy Phone

Responsible Party / Guardian (if patient is minor)

Guardian Full Name

Relationship to Patient

Guardian Date of Birth

Guardian Phone

Account Access

User Password *

Confirm Password *