ADRC Intake Form

ADRC Intake Form
Please be advised that the Ohio Department of Medicaid has put a temporary pause on processing referrals to the Ohio Home Care Waiver (OHCW) and Specialized Recovery Services (SRS) programs. This pause or hold on referrals is expected to remain in effect until on or about July 2, 2025. Referrals can still be made but will not be processed until this pause is lifted.
Do you give consent for storing your submitted information?*

Yes, I give permission to store and process my dataNo, I don't consent to storing and processing my data. STOP here. Do not fill out form. Instead, please call for assistance at 216-539-9240.
Date

YearMonthDay
Date
Due to an extremely high call volume, please allow several days for us to respond.
Person Making Referral*

First NameLast Name
Referrer's Email
example@example.com
Referrer's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Referrer's Company/Agency Name
Person Being Referred*

Legal First NameLegal Last Name
What County Is The Referred Person In Presently?
Enter County
Referred's Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Referred's Street Address Line 1*
Referred's Street Address Line 2
Referred's City*
Referred's ZIP Code*
Referred's Date of Birth

MonthDayYear
Date
Referred's Social Security Number
Referred's Gender

MaleFemaleOther
Who should we contact regarding this referral?
What is the relationship to the referred?
Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Is this number a cellphone?*

YesNo
Are we able to text this number?*

YesNo
*

By submitting this form, you consent to receive customer care messages from Western Reserve Area Agency on Aging at the number provided, including messages sent by an autodialer. Msg & data rates may apply. Msg frequency varies. Unsubscribe from any time by replying STOP to not receive messages from us. Reply HELP for help. Mobile information will not be shared with third parties/affiliates for marketing/promotional purposes.
What is the best time to reach you?
Select time of day.
Program Request (Choose only one from the list below)

Assisted Living (Age restriction, 21 and older)Community Information and Referral Only (telephonic)Connected Care Ohio TelehealthLong Term Care Consultation (non Medicaid) LTCCMyCare Ohio Waiver (For current MyCare Ohio members ONLY)Nursing Home PlacementOhio Home Care Waiver (Age restriction, 0-59 years old)Ohio Home Care Waiver to Passport (ONLY for current OHCW participants)PASSPORT (Age restriction, 60 and older)Specialized Recovery Services (Age restriction, 21 and older)
Does this person have Medicaid?

YesNo
*If Applying for Ohio Home Care Waiver, applicant must have Active Medicaid or have started a Medicaid application to request an assessment: Click here for online Medicaid application.
Type of Medicaid

Health Maintenance Organization (HMO)MyCare Ohio (MCO)Other, i.e., Specified Low Income Medicare Beneficiary (SLMB) or Qualified Medicare Beneficiary (QMB)
Plan Number
Diagnosis
Areas of Assistance Needed ADL's

BathingDressingSupervision Needed d/t Cognitive ImpairmentMedication AssistanceMobilityToileting
Areas of Assistance Needed IADL's

CleaningLaundryMeal PrepShoppingTransportation
Has the Referred person served in the military?

YesNo
Is there a Language Barrier or Other Communication Barrier?

YesNo
Please list Barrier
How did you hear about WRAAA?*
Additional Comments
Should be Empty: