New Prospective Member Questionnaire Application

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Office & Facility Address: 2500 Metro Centre Blvd Ste 7-8 West Palm Beach FL | For Assistance Call: 1-800-409-3804| 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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Responsible Party Filling Out Questionnaire* This field is required.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
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
Box1-Please select from drop down menu
Box2-Please type your name and relation to the prospective member, in example John Doe-Applicant
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Prospective Member* This field is required.Full name of prospective member in need of Adult Day Care Services
First Name
Last Name
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Date of BirthPlease type in the date of birth of the prospective member.
Month
Day
Year
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Email* This field is required.
example@example.com
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Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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
Curacao
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
Country
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Phone Number* This field is required.
Area Code
Phone Number
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Does prospective member require transportation to and from center?Please select YES or NO
YESNO
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Which day(s) would you be likely to use/recommend Daytime Adult Day Care Services? Please select the days of the week that apply.
Monday
Tuesday
Wednesday
Thursday
Friday
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Which hours would you be likely to use/recommend Daytime Adult Day Care Services? Please select the block schedule hours that apply
Morning -7:30AM-11:00AM
Afternoon -12:30PM-4:00PM
Evening-5:30PM-8:30PM
All Day Session 8:00AM-4:00PM
Custom-Part Time(1-3Hours/day)
Custom-Full Time(4-7Hours/day)
Extended Hours
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Is the prospective member immobile?Is the prospective member unable to move physically or is bedridden?
YESNO
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Does prospective member requires any of the following below while attending an adult day care?* This field is required.Please select all that applies
Wheel Chair
Motor Scooter
Cane
Walker
Oxygen Tank
Service Animal
Other
None
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Has the prospective member been violent or experience any violent episode towards anyone currently or in the past. Please answer if the prospective member have been physically violent with another person.
YESNO
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Does the prospective member suffers from any of the following below:Please select all that apply.
Anxiety Disorders
Depression
Bipolar Disorder
Eating Disorder
Post-Traumatic Stress Disorder
Schizophrenia
Obsessive-Compulsive Disorder
Personality Disorder
Psychotic Disorders
Alcoholism
Drug Abuse
ADHD
ODD
Other-Not Listed
None
Unknown
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Will the prospective member require any medication assistance while attending an Adult Day Care?Please select YES or NO
YESNO
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What is the cognitive ability of the prospective member? Please check all that apply
No cognitive concerns
Alert & oriented to time and place
Requires assistance 24hours
Requires daily living assistance
Disturbed sleeping patterns
Remembers past conversation
Remembers close family names
Remembers spouse name
Constant anxiety & agitation
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Can the prospective member feed him or her-self with little to no assistance?* This field is required.Meaning prospective member can or cannot hold utensils on their own. Please select YES or NO
YESNO
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Special DietsPlease select each special diet that pertains to the prospective member.
Regular Diet
Mechanical Diet (Chopped or Soft)
Clear Liquid Diet(Little Residue)
Full Liquid Diet
GI Soft Diet
Low Residue/Low Fiber
Salt Restricted/Low Sodium
Fat Restricted Diet
Cholesterol-Restricted Diet
Vegetarian Diet
Consistent Carbohydrate(Diabetic)
Renal Diet
Kosher Diet
Vegan Diet
Other Not Listed Diet
None Required
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Does the prospective member currently have the following or requires any of the following assistance listed below?* This field is required.Please select all that apply.
Currently have a colostomy bag
Urinal must be used during attendance at Adult Day Care Center
Requires limited assistance in lavatory
Requires no assistance in lavatory
Wears depends or other incontinence undergarments
Currently have a catheter
Must be reminded to use lavatory
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COVID-19 Questions* This field is required.Please select all that apply pertaining to prospective member regarding COVID-19.
Prospective member tested positive for COVID-19 in the last 30 days
Prospective member resides or previously lived with someone who tested positive for COVID-19
Prospective member never received any COVID-19 testing
Prospective member did test positive for COVID-19 in the past but a follow-up test shows negative.
If membership is granted prospective member will be flying in from a state reported of high levels of COVID-19 positive cases.
Prospective member is transitioning from an assisted living or nursing home impacted by COVID-19
Prospective member is a parent of an active frontline worker or the caregiver for the prospective member is an active frontline worker
Prospective member is currently experiencing COVID-19 symptoms or flu like symptoms
Prospective member is currently or within the last 14 days been ordered by a public health or medical professional to self-monitor, self-isolate, or self-quarantine because of concerns about COVID-19 infection.
Prospective member caregiver or legal power of attorney is unemployed due to COVID-19 and requires immediate services for prospective member in order to receive caregivers relief and seek employment.
Prospective member is WILLING to be tested for COVID-19
Prospective member DOES NOT want to ever be tested for COVID-19
Prospective member came in close contact with anyone who has COVID-19 (close contact meaning with-in 6ft)
Prospective member shared or experience fluid of someone with COVID-19 (shared a drink, eating utensils, was coughed on by accident or etc.)
NONE OF THE ABOVE APPLY
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Is the prospective member a former member or related to any of World Wide Health Services Adult Day Care team?Please select YES or NO.
YESNO
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What is the adult day care status of the prospective member?* This field is required.Please select the best answer
Never attended an adult day care
Currently attend an adult day care
Attended an adult day care in the past
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If membership is granted please list the intended source of payment for requested World Wide Health Services Adult Day Care ServicesPlease select all that apply.
Private Pay/Self Pay
Manage Care- Medicaid
WWHS In House Grant
Long Term Care Insurance
Commercial/Private Insurance
Veterans Benefit/VACCN
Other/Not Listed
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Insurance Information (PRIVATE PAY PLEASE SKIP TO NEXT FIELD)If you are using insurance as a payment option please fill out information below
Member ID
Aetna
FCC-Florida Community Care
Humana
Molina
Other Not Listed
Simply
Staywell/Well Care
Sunshine
United HealthCare
Veterans Benefit
Please Select Your Insurance Carrier
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Thank you for filling out the New Prospective Member Questionnaire. Please let us know how did you hear about World Wide Health Services Adult Day Care?Please type your answer below and click submit.
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