FQHC Project Intake Form
Add Another Lead
Submitter
Agent
Clinic
PSR
Project
*
Enter the project code to load available locations
Please Select a Project
Location
*
Please Select
Agent NPN (Optional)
If NPN is provided, this will route the submission to the appropriate agent
Please Select a PSR
New Lead
Log a Visit
New
Member Information
Member Information
Member Status
Please Select
Member First Name
*
Member Last Name
*
Gender
*
Please Select
Date of Birth
Primary Phone #
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Country
MBI #
Medicaid #
Effective Date
Carrier
Please Select
Benefit Plan Name
IPA / Medical Group
PCP Name
Enrollment Confirmation #
Lead Source
Please Select
Submit Enrollment
Visit Details
Type of Event
*
Please Select
Date of Event
*
Time In
Time Out
Off-Site Appointments
Enrollments
No Shows
Service Issues
Member Engagement
Notes
Log Visit