Home-Based Asthma Interventions VAB Form

This form is designed to identify and refer members who may benefit from Home-Based Asthma Interventions value-added benefit provided by DFH. These interventions aim to support members in managing their asthma effectively within their home environment, improving health outcomes and reducing complications. Please complete this form to ensure eligible members receive the appropriate resources and assistance.

Member's First Name *

Member's Last Name *

Date of Birth *

Medicaid ID# *

Member's Phone Number

Does the member have an asthma diagnosis? * Yes No

When did you last see this member for asthma treatment? * Enter Date

Which of the following home-based interventions do you recommend for this member? [Select all that apply] * Hypoallergenic bedding (dust mite mattress and pillow encasing) Air Purifier Pest Control

Kindly advise the member that DFH may contact them by phone in relation to this request.

Additional Comments [Optional]

Provider's Name *

Provider's Phone Number *