New Member Evaluation — Pacific Health Group

Member information

Tell us how to reach you.

First name *

Last name *

Date of birth *

Health plan

CIN

Preferred language

Phone number *

Alternate phone

Back-up contact name

Back-up contact phone

Current location (address or description)

City

State

ZIP code

Consent

ECM consent is only required if you selected Enhanced Care Management. For Community Supports, CHW, Street Medicine, or Behavioral Health, your care team will walk you through any program-specific consent at intake.

ECM consent (required only if ECM selected)

VerbalWrittenDeclinedN/A

Reason for declining

Opt-in date

Consent obtained by

HIPAA-protected. We respond within one business day.

Tell us a bit about you — we'll take it from here.

Member information

Programs & focus

What do you need most right now?

Consent