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RightCare Member Needs Screening

Member Needs Screening

Please use one form for each new RightCare member. We ask that you complete this form to the best of your ability as it will allow our Service Coordinators to get to know you and assess your health needs and address your concerns. If you have questions or need help, please call us at 1.855.897.4448 and ask for a Service Coordinator. TTY/TTD users, please call 7-1-1.

These answers will be shared with your healthcare team and Service Coordinator.

To complete this screening online, please visit: https://survey.alchemer.com/s3/7012903/Health-Assessment. 

On page two, you will find the Spanish version of this survey. 
 
Please enter your information below:
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1. How is the member’s general health?

Excellent
Average
Very Poor
2. Is the member pregnant?
3. Is the member a farm worker (work in the fields/agriculture or travel for work)? 
If so, we may be able to help with services before leaving our area.
4. Does the member use any special equipment to help with walking, talking, hearing, breathing or feeding?
 
6. Has the member been diagnosed with or have problem with any of the following? (Check all that apply.)
7. What is the member’s housing situation today?
8. Think about the place the member lives. Does the member have problems with any of the following?
9. Within the past 12 months, has the member run out of food or worried that food would run out before they got money to buy more?
10. In the past 12 months, has lack of transportation kept the member from medical appointments, meetings, work, or getting things needed for daily living?
11. In the past 12 months, has the electric, gas, oil or water company threatened to shut off services in the member’s home?   
12. How often does anyone, including family, physically hurt the member?
13. How often does anyone, including family, insult or talk down to the member?
14. How often does anyone, including family, threaten the member with harm?
15. How often does anyone, including family, scream or curse at the member?
16. Is the member willing to receive a call from one of our team members if we feel you could benefit from Service Coordination?