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Date
-
Year
-
Month
Day
Date
Person Making Referral
First Name
Last Name
Referral Email
example@example.com
Referral Phone Number
Please enter a valid phone number.
Company Name
Person Being Referred
*
Legal First Name
Legal Last Name
Referred Phone Number
*
Please enter a valid phone number.
Referred Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Referred Date of Birth
-
Month
-
Day
Year
Date
Referred Social Security Number
Referred Gender
Male
Female
Other
Who should we contact regarding this referral?
Contact Phone Number
*
Please enter a valid phone number.
Program Request
Assisted Living
Community Information and Referral Only (telephonic)
Connected Care Ohio Telehealth
Long Term Care Consultation (non Medicaid) LTCC
Nursing Home Placement
Ohio Home Care Waiver
Ohio Home Care Waiver to Passport
PASSPORT
Specialized Recovery Services
Diagnosis
Areas of Assistance Needed ADL's
Bathing
Dressing
Supervision Needed d/t Cognitive Impairment
Medication Assistance
Mobility
Toileting
Areas of Assistance Needed IADL's
Cleaning
Laundry
Meal Prep
Shopping
Transportation
Does this person have Medicaid?
Yes
No
Type of Medicaid
HMO
MCO
Plan Number
Is Referred Person a My Care Ohio Member (Buckeye, CareSource or United)? If yes, please contact their Managed Care Organization and DO NOT SUBMIT Intake Form to WRAAA.
Yes
No
Is Referred Person a My Care Ohio Member?
Is Referred Person a Veteran
Yes
No
Is there a Language Barrier or Other Communication Barrier?
Yes
No
Please list Barrier.
How did you hear about WRAAA?
*
Please Select
Health Care Professional
Social Worker
Community Outreach Event
Senior Center
Friend or Relative
Word of Mouth
Additional Comments
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