№ lp_2_3_32023
Official health plan correspondence and standardized state health risk assessment form used in Minnesota to collect member information on living situation, functional status, behavioral health, and substance use for care coordination purposes.
Organization: HealthPartners Inspire
Program: Special Needs Basic Care (SNBC)
Document Type: Member outreach letter and health risk assessment form
Form Title: Minnesota Health Risk Assessment Form
Form Number: DHS-3428H-ENG
Approval Date: 8/22/2016
Revision Date: 8-18
State: Minnesota
Target Population: Health plan members, including SNBC members
Sections: Member Information; Living Situation and Housing; Dental Care; Activities of Daily Living; Emotional Health; Substance Use; Subjective Evaluation of Health
Enclosures: Statement of Nondiscrimination for Health Plan Members; Language Block; Health Assessment; Self-addressed Stamped Envelope
Price: 8 / 10 USD
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