Health Needs Survey Form

You do not need to sign in to complete this survey.

Welcome to Health Plan of Nevada Medicaid! Your health is important to us. That’s why we need a little more information to help provide you and your family with quality care to meet your medical needs. Please take a few minutes to fill out this form. Each adult over 18 in the home needs to complete their own form. Your answers are confidential and will only be used to assist you and your family with medical care. If you need help filling out this form, call us toll-free at 1-800-962-8074, TTY 711, Monday through Friday, 8 a.m. to 6 p.m. If we have any questions, we may reach out to you.

You may also choose to download a PDF version of the form to be filled out and mailed in.

Please answer the following questions:

Your First Name:

The Your First Name: field is required.

Your Last Name:

The Your Last Name: field is required.

Date of Birth:

The Date of Birth: field is required.

Medicaid ID #:

The Medicaid ID #: field is required.

Primary Care Provider:

Do we have permission to contact you by email/text?

Yes No

The language(s) we usually speak at home:

The language(s) we usually read and write at home:

Do you have any other health care insurance coverage? If yes, please list:

If there are no other members in your household, please skip to question #6. Family members enrolled in Health Plan of Nevada's Medicaid or Nevada Check Up Program are:

Child 1: First Name:

Child 1: Date of Birth:

Child 1: Medicaid ID #:

Child 1: Primary Care Provider:

Child 1: Are they up-to-date with all their shots?

No Yes Not Sure

Child 2: First Name:

Child 2: Date of Birth:

Child 2: Medicaid ID #:

Child 2: Primary Care Provider:

Child 2: Are they up-to-date with all their shots?

No Yes Not Sure

Child 3: First Name:

Child 3: Date of Birth:

Child 3: Medicaid ID #:

Child 3: Primary Care Provider:

Child 3: Are they up-to-date with all their shots?

No Yes Not Sure

Child 4: First Name:

Child 4: Date of Birth:

Child 4: Medicaid ID #:

Child 4: Primary Care Provider:

Child 4: Are they up-to-date with all their shots?

No Yes Not Sure

Please answer these questions to help us take better care of you and your family members who are enrolled in Health Plan of Nevada: Your answers are confidential as governed by Federal and State Law and will only be used to assist you with your medical care. If there are no children in your household, please skip to question #6.

1. Does your child have any medical conditions? This is something that could require many doctor’s visits and regular medications.

No Yes

2. Does your child have any kind of emotional, developmental, or behavioral health condition for which they need to get treatment or counseling?

No Yes

3. If you answered yes to the previous questions, would you like one of our Care Managers to contact you about our programs and services?

No Yes

4. Has your child had a regular checkup with their doctor in the last year?

No Yes

5. Has your child seen a dentist in the last year?

No Yes

6. During the past year, were you or anyone in your family admitted for an overnight stay in a hospital?

No Yes

During the past year, have you or anyone in your family received medical care in a hospital emergency room?

No Yes

Name of person 1 admitted or in the ER:

Name of Person 2 admitted or in ER:

7. Have you been told you have a medical condition? This is something that could require many doctor’s visits and regular medications.

No Yes

8. Do you have any kind of emotional, developmental, or behavioral conditions for which you need or get treatment or counseling?

No Yes

9. If you answered yes to the previous questions, would you like one of our Care Managers to contact you about our programs and services?

No Yes

10. Have you received any of the following services in the past year?

Yearly checkup COVID-19 vaccine Cervical cancer screening/Pap smear Colorectal screening Flu shot Mammogram None Choose not to answer

11. Are you, or anyone in your household pregnant that is covered by HPN Medicaid?

No Yes

If “yes”, please provide the following information. (Include yourself if it applies):

Date of Birth of Person 1:

Due Date of Person 1:

Date of Birth of Person 2:

Due Date of Person 2:

Have you or they seen a doctor for this pregnancy?

No Yes

Have you or they been told this is a high-risk pregnancy?

No Yes

Are you or they on any prescription medications for pain, or other narcotics?

No Yes

Would you like one of our Care Managers to contact you about our programs and services?

No Yes

12. Is it hard for you to concentrate, remember things, or make decisions?

No Yes

13. Over the last two weeks, how often have you been bothered by little interest or pleasure in doing things?

Not at all Several days More than half the days Nearly every day No Response

14. Over the last two weeks, how often have you been feeling down, depressed or hopeless?

Not at all Several days More than half the days Nearly every day No Response

15. Has alcohol or drug use made it hard for you to work, keep relationships, or meet goals?

No Yes

16. Have you been unable to get daily necessities? These could be things like childcare, food, transportation, ID card, cell phone, rent or utilities.

No Yes

Would you like help with getting these resources?

No Yes

17. What is your housing situation today?

I have housing I have housing, and part of my rent is paid by a housing assistance program I do not have housing I have temporary housing

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Health Needs Survey Form

You do not need to sign in to complete this survey.

Please answer the following questions:

If there are no other members in your household, please skip to question #6. Family members enrolled in Health Plan of Nevada's Medicaid or Nevada Check Up Program are: