Care Options Referral Form

This HIPAA-compliant referral form will be submitted to an Options Counselor to begin the care options review process. Information submitted through this form is secure (encrypted when transmitted between systems or when stored).
Contact Information

Once received, an Options Counselor will contact you. For your convenience, please provide the following information to best reach you.
Contact Time
Preferred Contact Method
Referred Person's Zip Code
If your zip code is not shown please do not complete this form. Please call for more information
Individual Making the Referral
Name of Individual Making the Referral

First NameLast Name
Referring Organization
Company name
Relationship to Referred Person
Phone (Individual Making the Referral)
Please enter a valid phone number.Format: (000) 000-0000.
ExtensionFormat: 0000000.
Email (Individual Making the Referral)
example@example.com
Fax (Individual Making the Referral)
Please enter a valid fax number.Format: (000) 000-0000.
Referred Person's Information
Name

First NameLast Name
Preferred Name (If Different from Above)
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender Identity
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Alternate Phone
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Who would you like us to contact to follow up on this referral?
Secondary Contact Name

First NameLast Name
Secondary Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Contact Email
example@example.com
Referred Person's Financial Information
Type of Insurance

Other
Person's Gross Monthly Income (Do not include spousal income)
Relationship Status

Option Not Listed, Please Specify:
Person's Total Assets
Assets include money in the bank, stocks, bonds, CDs, IRA, etc. Excludes home and car.
Married Couple's Total Assets
Assets include money in the bank, stocks, bonds, CDs, IRA, etc. Excludes home and car. Spousal impoverishment asset amounts apply if married, call (231) 733-3585 for more information.
Veteran Status
Referred Person's Assessment of Needs
Person is at:

Other
Person lives alone?
Needs Assistance with Personal Tasks:

Other
Needs Assistance with Daily Tasks

Other
Medical Needs

Other
Assistive Devices in Use

Other
Diagnosis / Medical Issues
Services Needed
Additional Information / Special Needed
Should be Empty:

Contact Information

Individual Making the Referral

Referred Person's Information

Referred Person's Financial Information

Referred Person's Assessment of Needs