OPTA Health — CHW Program

CHW Support Request

Tell us about your facility and the level of CHW support you need. Our care coordination team will follow up to discuss patient details through a secure channel.

No patient information is collected here. This form captures only your facility and contact details. All clinical and patient-specific information will be exchanged through a HIPAA-compliant channel after our team reaches out to you.

Routine

Response: 2 business days

Priority

Response: 1 business day

Urgent

Response: Within 4 hours

Referring Facility

Your organization and contact details

CHW Support Needs

General information about the support required — no patient details needed here

Rough estimate is fine

Describe the type of CHW support needed — e.g. post-discharge follow-up, SDOH barriers, medication adherence. Do not include patient names, DOB, or diagnosis.

Anything else that would help us prepare for the follow-up call

By submitting, you confirm this request does not contain any protected health information (PHI). Patient details will be collected securely after our team contacts you.