Phone2Home

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PROGRAM GOALS

Help to connect people with the services they need.
Reduce preventable ER visits.
Educate the community about alternatives to the E.R.
Enroll the uninsured/underinsured with a Medical Home
Improve health outcomes and quality of life

GET CONNECTED WITH

Medical & Dental Services
Chronic Disease Management
Nutrition & Food Assistance Programs
Education & Employment Programs
Affordable Housing Programs
Transportation Services
Home Health/Respite Care

Phone2Home Consent Form

Phone2Home
Registration and Consent Form

Description of Services:

The Phone2Home Program is a partnership between Osceola Community Health Services, Osceola County Emergency Services, and other community partners. The main goal of the program is to reduce preventable emergency room visits by providing participants with care management services and connecting them with affordable health services and community resources.

* Patient Name: (Required)

Osceola Community Health Services Patient? Yes No

E-mail:

Phone Number:

Home Address:

City:

State:

Zip:

INFORMED CONSENT TO RECEIVE SERVICES

I agree to participate in the Phone2Home Program care management program administered by Osceola Community Health Services. Services may include general health education, monitoring, compliance counseling and coordination of care as related to general health and social needs. I agree to being contacted by telephone, email, in writing, and in person by the Phone2Home care managers. The care management program is voluntary, and I may withdraw from the program at any time upon notification.

Electronic Signature: (Required)

Date of Electronic Signature:

Security Measure

Phone2Home

Phone2Home Registration and Consent Form

Description of Services:

INFORMED CONSENT TO RECEIVE SERVICES

Phone2Home
Registration and Consent Form