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For Providers

Referrals for the Children's Health Home can be submitted through eRecord, faxed to (585)341-9430 or emailed to

A Health Home is a care management service model where all of an individual's providers communicate with one another so the patient's needs are addressed in a comprehensive manner. This is done primarily through a care manager. Health records are shared among providers so that services are not duplicated or neglected. Health Home services are provided through a network of organizations - providers, health plans and community-based organizations. When all the services are considered collectively they become a virtual Health Home.

Role of the Care Managers

Children's Health HomeA Care Manager is a trained professional, who makes sure the child and family have the services they need, such as:

  • Appointments
  • Medications
  • Safe place to live
  • Insurance
  • Transportation to appointments

The Care Manager sets up a care plan that lists the child's needs and goals and helps determine which providers and services are required to reach those goals.


The child can be enrolled at any time and must be covered under Medicaid or a Managed Medicaid Insurance Company (MCO) and

  • Have 1 single qualifying condition (HIV/AIDS, serious emotional disturbance or complex trauma); OR
    Have 2 or more chronic conditions (diabetes, asthma, obesity, etc.)
  • Have significant behavioral, medical or social risk factors (death, disability, inadequate housing, etc.)

We are currently not accepting patients who are in a Waiver Program, Foster Care or who receive Early Intervention Services.

Please provide families with the Patient and Family Fact sheet to help them understand the program.