Asthma Home Based Services - Southwest Health and Human Services

Eligibility for the Program

About the Program

Includes up to three FREE home visits from a Public Health Nurse that specializes in Asthma Management

How the program can help you

Learn about asthma triggers in your home
Reduce your child’s asthma symptoms and improve control

Children ages 0-17 diagnosed with asthma or asthma like symptoms
Lives in Lincoln, Lyon, Murray, Pipestone, Redwood or Rock County

Public Health Asthma Home-Based Services Referral Form

Fill out the form below to send a referral for Asthma Home Based Services.

Parent/Guardian Name(Required)

First Last

Phone(Required)

Language Spoken(Required)

Interpreter Needed(Required)

Yes

Your Address(Required)

Street Address Address Line 2 City ZIP Code

Child's Name(Required)

First Last

Child's DOB(Required)

Reason for Referral(Required)

Insurance:(Required)

Private

Other

None

Private Insurance Name or Other Name

Primary Care Provider

Specialist

Medication List

Additional Information

DATA PRIVACY NOTICE

The information requested on this form is intended to be used by Southwest Health and Human Services in determining suitability for the Public Health Home-Based Asthma Program.

Minnesota Department of Health Services

Link to the Minnesota Department of Health Asthma Home-Based Services webpage