Fallon Health Care Needs Screening

Please take a few minutes to complete this screening. Your Care Needs Screening will help Fallon Health provide better health services and coordinate the care you receive. We will keep the information you provide private. By submitting this form, you are giving us permission to share your information with the people involved in your care. Your answers will not affect your MassHealth/Medicaid benefits.

 Please note that this screening tool does NOT take the place of a medical evaluation with your Primary Care Provider. If you have any urgent medical or behavioral health needs, please schedule an appointment with your Primary Care Provider, or go to your nearest emergency care center.

Survey instructions:

1. Please fill out one screening form for each new member.
2. You will need to have on hand:
• Your plan member ID number
• The name, phone number, and address of your doctor or nurse.
3. Answer each of the questions by checking the appropriate box or filling in the space provided.
4. You are sometimes told to skip over some questions in this survey. When this happens, you will see a note that tells you what question to answer next.
5. This survey will take about 15 minutes to complete.
6. If you need help or have questions about completing this form, please call Customer Service at the number on the back of your member ID card, Monday through Friday from 8 a.m. to 6 p.m.