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New Prospective Member Questionnaire Application
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    | Private Pay Options Available | Trust | Medicaid & Most Major Insurance Accepted | Now Accepting New Members | ADC-9397
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    Welcome: Introduction

    Thank you for choosing World Wide Health Services Adult Day Care. If you are an insured prospective member, that will be using insurance as a form of payment, prior to filling out this form please contact your insurance policy for authorization. This questionnaire is for new prospective members only and filling out this online questionnaire is not a guarantee into our program as everyone will be evaluated on a case by case basis to ensure that our program is the right fit for the prospective individual seeking services. After processing your online questionnaire, if it is determined that World Wide Health Services Adult Day Care will or will not be a good fit based on the answers provided, you will be notified via email, fax, phone, and or mail of the decision. If World Wide Health Services Adult Day Center determines that our services will be beneficial for the prospective member, you will be notified of the next process.

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    3 Step Processing 

    Please be aware that membership into our program is at the discretion of World Wide Health Services and there is a three step process required for membership approval which are:

    1. New Prospective Member Questionnaire

    2. Online/ Phone Evaluation Assessment(Once receive acceptance notice)

    3. Paper Work Processing- All requested applications, forms, laboratory test/ physicals, signed medical release records, signed WWHS Adult Day Care Category service outline including payment forms and or insurance information and all additional requested documents and or fees associated for processing.

    If anyone requires assistance in filling out this questionnaire, please contact World Wide Health Services Adult Day Care at 1-800-409-3804 Ext 808 between the hours of 12pm-4pm Est. Monday-Friday  to speak or set an appointment with a remote team member. Filling out this questionnaire is at the will and risk of the individual filling out the information. Questionnaire details may change as needed with or without notice at the discretion of World Wide Health Services Adult Day Care and World Wide Health Services entity or its affiliates hold no liability for any misrepresentation, misguided, and misinformed information provided. If you agree to the terms listed above, please select Next to continue.

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    Please inform us of who is filling out this questionnaire by selecting the appropriate response from box 1 drop down selection. Are you the applicant, caregiver, family member, health care provider, social worker, insurance placement representative, contracted emergency placement, or other authorized legal representative. Please also type in your name and relation to the prospective member in the second box. For example my name is John Doe and I am the applicant I would type in John Doe-Applicant in box 2.
    Please Select Best Response
    • Applicant
    • WSC(FOR APD)
    • Caregiver
    • Family Member
    • Health Care Provider
    • Social Worker
    • WWHS- INTAKE REP(PLEASE ENTER REP ID IN BOX2)
    • Insurance Placement
    • Emergency Placement
    • Other Authorized Legal Representative
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    Full name of prospective member in need of Adult Day Care Services
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    Please type in the date of birth of the prospective member.
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    Pick a Date
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    Please Select
    • Please Select
    • United States
    • Afghanistan
    • Albania
    • Algeria
    • American Samoa
    • Andorra
    • Angola
    • Anguilla
    • Antigua and Barbuda
    • Argentina
    • Armenia
    • Aruba
    • Australia
    • Austria
    • Azerbaijan
    • The Bahamas
    • Bahrain
    • Bangladesh
    • Barbados
    • Belarus
    • Belgium
    • Belize
    • Benin
    • Bermuda
    • Bhutan
    • Bolivia
    • Bosnia and Herzegovina
    • Botswana
    • Brazil
    • Brunei
    • Bulgaria
    • Burkina Faso
    • Burundi
    • Cambodia
    • Cameroon
    • Canada
    • Cape Verde
    • Cayman Islands
    • Central African Republic
    • Chad
    • Chile
    • China
    • Christmas Island
    • Cocos (Keeling) Islands
    • Colombia
    • Comoros
    • Congo
    • Cook Islands
    • Costa Rica
    • Cote d'Ivoire
    • Croatia
    • Cuba
    • Curaçao
    • Cyprus
    • Czech Republic
    • Democratic Republic of the Congo
    • Denmark
    • Djibouti
    • Dominica
    • Dominican Republic
    • Ecuador
    • Egypt
    • El Salvador
    • Equatorial Guinea
    • Eritrea
    • Estonia
    • Ethiopia
    • Falkland Islands
    • Faroe Islands
    • Fiji
    • Finland
    • France
    • French Polynesia
    • Gabon
    • The Gambia
    • Georgia
    • Germany
    • Ghana
    • Gibraltar
    • Greece
    • Greenland
    • Grenada
    • Guadeloupe
    • Guam
    • Guatemala
    • Guernsey
    • Guinea
    • Guinea-Bissau
    • Guyana
    • Haiti
    • Honduras
    • Hong Kong
    • Hungary
    • Iceland
    • India
    • Indonesia
    • Iran
    • Iraq
    • Ireland
    • Israel
    • Italy
    • Jamaica
    • Japan
    • Jersey
    • Jordan
    • Kazakhstan
    • Kenya
    • Kiribati
    • North Korea
    • South Korea
    • Kosovo
    • Kuwait
    • Kyrgyzstan
    • Laos
    • Latvia
    • Lebanon
    • Lesotho
    • Liberia
    • Libya
    • Liechtenstein
    • Lithuania
    • Luxembourg
    • Macau
    • Macedonia
    • Madagascar
    • Malawi
    • Malaysia
    • Maldives
    • Mali
    • Malta
    • Marshall Islands
    • Martinique
    • Mauritania
    • Mauritius
    • Mayotte
    • Mexico
    • Micronesia
    • Moldova
    • Monaco
    • Mongolia
    • Montenegro
    • Montserrat
    • Morocco
    • Mozambique
    • Myanmar
    • Nagorno-Karabakh
    • Namibia
    • Nauru
    • Nepal
    • Netherlands
    • Netherlands Antilles
    • New Caledonia
    • New Zealand
    • Nicaragua
    • Niger
    • Nigeria
    • Niue
    • Norfolk Island
    • Turkish Republic of Northern Cyprus
    • Northern Mariana
    • Norway
    • Oman
    • Pakistan
    • Palau
    • Palestine
    • Panama
    • Papua New Guinea
    • Paraguay
    • Peru
    • Philippines
    • Pitcairn Islands
    • Poland
    • Portugal
    • Puerto Rico
    • Qatar
    • Republic of the Congo
    • Romania
    • Russia
    • Rwanda
    • Saint Barthelemy
    • Saint Helena
    • Saint Kitts and Nevis
    • Saint Lucia
    • Saint Martin
    • Saint Pierre and Miquelon
    • Saint Vincent and the Grenadines
    • Samoa
    • San Marino
    • Sao Tome and Principe
    • Saudi Arabia
    • Senegal
    • Serbia
    • Seychelles
    • Sierra Leone
    • Singapore
    • Slovakia
    • Slovenia
    • Solomon Islands
    • Somalia
    • Somaliland
    • South Africa
    • South Ossetia
    • South Sudan
    • Spain
    • Sri Lanka
    • Sudan
    • Suriname
    • Svalbard
    • eSwatini
    • Sweden
    • Switzerland
    • Syria
    • Taiwan
    • Tajikistan
    • Tanzania
    • Thailand
    • Timor-Leste
    • Togo
    • Tokelau
    • Tonga
    • Transnistria Pridnestrovie
    • Trinidad and Tobago
    • Tristan da Cunha
    • Tunisia
    • Turkey
    • Turkmenistan
    • Turks and Caicos Islands
    • Tuvalu
    • Uganda
    • Ukraine
    • United Arab Emirates
    • United Kingdom
    • Uruguay
    • Uzbekistan
    • Vanuatu
    • Vatican City
    • Venezuela
    • Vietnam
    • British Virgin Islands
    • Isle of Man
    • US Virgin Islands
    • Wallis and Futuna
    • Western Sahara
    • Yemen
    • Zambia
    • Zimbabwe
    • Other
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    Please select YES or NO
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    Please select the days of the week that apply.
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    Please select the block schedule hours that apply
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    Is the prospective member unable to move physically or is bedridden?
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    Choose yes only if the prospective member cannot participate in a group setting and the prospective member will require a designated staff person only for them due to his or her disability. Choose no if the prospective member can participate in a group setting but may require additional support.
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    Please select all that applies
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    Please answer if the prospective member have been physically violent with another person.
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    Please select all that apply.
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    Please select YES or NO
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    Please check all that apply
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    Please type any current disabilities that the prospective member may have. If none please type "none"
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    Meaning prospective member can or cannot hold utensils on their own. Please select YES or NO
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    Please select each special diet that pertains to the prospective member.
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    Please select all that apply.
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    Please select all that apply pertaining to prospective member regarding COVID-19.
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    Please select YES or NO.
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    Please select the best answer
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    If you are using insurance as a payment option please fill out information below
    • Aetna
    • APD-Agency For Person With Disabilities
    • FCC-Florida Community Care
    • Humana
    • Molina
    • Other Not Listed
    • Simply
    • Staywell/Well Care
    • Sunshine
    • United HealthCare
    • Veterans Benefit
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    Please add Copy of Prospective Members Insurance Card
    Drag and drop files here
    Select files to upload
    Max. file size: 10.6MB
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    Please add Copy of Prospective Member Valid Picture ID (Example Drivers license)
    Drag and drop files here
    Select files to upload
    Max. file size: 10.6MB
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    Please add Copy of Prospective Member Insurance Approved Authorization Form
    Drag and drop files here
    Select files to upload
    Max. file size: 10.6MB
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    Please type your answer below and click submit.
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