HOP Screening Form Questions

 Thank you for your interest in the Healthy Opportunities Pilot (HOP). HOP is only available for Medicaid Managed Care recipients that lives in one of the 33 counties in North Carolina that HOP provides services for. To be pre-screened, please complete the questions below, and a Good Shepherd HOP Navigator will reach out to complete the pre-screening process. 

1. Who are you completing this form for? (yourself or are you a parent or gradian of recipient)
2.  Name of Medicaid Managed Care Recipient? (Enter first and last name)
3.  County of Residence?
4.  Medicaid Managed Care Plan Provider?
5. Member Medicaid ID number from Insurance/PHP Card?  (Member ID is 9 digits and a letter; Member ID is not required, but will reduce processing delays)
6. Address, City and Zip Code? (required)
7. Date Of Birth? (Please enter for the Medicaid Managed Care recipient)
8.  Best Phone Number to reach you?
9.  Is it ok to leave a message? (Yes or No)
10.  Is there a best time to reach you? (Insert best time)
11.  How did you hear of HOP?

COPY AND ANSWER QUESTIONS IN EMAIL PROVIDED BELOW