SFC FH Eligibility Web Screen

See If Your Family Qualifies
This form is for families or individuals who are interested in either Structured Family Caregiver or Family Hire. Before completing this form, you should review the income and asset limitations for Medicaid and take care of any strategic planning necessary for qualifying for Medicaid home care services.

Information Links
Structured Family Caregiver | Family Hire | Medicaid Eligibility
What type of services are you seeking?*

Traditional in-home care services (provider sends caregivers to work in the home)Structured family caregiver services (family member is paid to care for care recipient)Family Hire (relative paid as employee to care for care recipient)None of the above
Thank you for your interest in our services. You may view our other offerings by returning to our website and viewing our Services page.
This questionnaire is to screen for Structured Family Caregiver (SFC) and Family Hire (FH) eligibility. If you are interested in Medicaid funded traditional home care services where a non-related caregiver works in the home, complete our PSS Intake Form.
EDWP Status

The care recipient is the person needing services or care.
Does the care recipient have Medicaid or Medicare?*

Only MedicaidOnly MedicareNeitherBothNot sure
The care recipient must be an active Medicaid Member in order to qualify for SFC or FH services.

We can check the care recipient's eligibility for Medicaid if you continue answering the questions below.
Is the care recipient already receiving Medicaid home care (personal support) services through CCSP, SOURCE, or ICWP?*

YesNoCare Recipient is approved but has not yet started receiving services.Not sure
Is (or was) the care recipient already approved for Structured Family Caregiver or other home care services?*

YesNoCare Recipient is approved but has not yet started receiving services.Not sure
Home Care Provider Name
Home Care Provider from which the Care Recipient receives services
Why is the care recipient (or family caregiver) seeking a new home care provider?
Please explain why the care recipient is seeking a new SFC provider.
Does the Medicaid Member (Care Recipient) have a cost share?*

YesNo
How much is the monthly cost share?
*We may be able to assist some families in meeting their cost share obligations.
To become a paid Family Caregiver in the Structured Family Caregiver program, the caregiver must meet the following requirements. Please read the following requirements carefully and click the checkbox on each line to show acknowledgement.*

At least 18 years oldLive in same home with member (care recipient / participant)Not employedNot self-employedCannot be the parent (if the care recipient is a minor)Cannot be the spouse of the memberCannot be the member’s conservator or legally appointed guardianMust pass background checkMust log tasks and submit notes daily through SFC provider’s secure electronic app or websiteMust communicate pertinent information to member, Health Coach, and/or case managerMust partake in SFC provider training on how to use the tools of a home care aide, which include blood pressure cuff, stethoscope, thermometer, gloves, gowns, aprons, shampoo boards and medical records.Must complete 8 hours of training every yearMust speak with Health Coach at least once per month (by appointment)Must meet Health Coach and Case manager in person at the member’s home, at least twice per yearMust notify the team when member is admitted to/discharged from the hospital or other care facilities
To become a paid employee in the Family Hire program, the caregiver must meet the same requirements that a non-related home care aide must meet in the state of Georgia. Please read the following requirements carefully and click the checkbox on each line to show acknowledgement.*

At least 18 years oldCannot be the spouse of the memberCannot be the parent (if the care recipient is a minor)Cannot be the member’s conservator or legally appointed guardianMust pass the Personal Care Aide (PCA) test (training is provided)Active CPR and First Aid Certification requiredTB test required (annually)Full employment application is requiredMust pass fingerprint background checkCare recipient's paid visit days and hours are pre-scheduled based on a care planMust clock in and out for the scheduled visits at the care recipient's home using Electronic Visit VerificationMust complete periodic trainingMust notify staff when member is admitted to/discharged from the hospital or other care facilities
Would you like for us to check whether the care recipient is already eligible for EDWP services?*

YesNo
Would you like for us to submit an inquiry to the care recipient's local Area Agency on Aging to get the qualification process started?*

YesNo
Is the Care Recipient's gross income $943/month or less?*

YesNoNot Sure
Is the Care Recipient's monthly income from all sources of income $2,829 or less?*

YesNoNot Sure
The care recipient does not appear to be eligible for Georgia Medicaid's EDWP services at this time.

There is a current individual monthly income cap for eligibility of $2,829 for all sources of income combined. Individuals with a higher income should contact an attorney regarding a Qualified Income Trust if interested in receiving EDWP services.

To view our private pay home care programs, please visit our website.
Would you like for us to make contact with the Care Recipient's case manager to request a switch to Structured Family Caregiver program?*

YesNo, I will contact the case manager.
Care Recipient (Patient) Information

This section pertains to the person needing care / services.
Care Recipient (Patient) Name*
Birth Date*

MonthDayYear
Care Recipient (Patient) Birth Date
Gender*

MaleFemale
Care Recipient Address

Street Address

Street Address Line 2

CityState (Must be Georgia)

Zip Code
City
What city does the Care Recipient live in? Select from the list.
Care Recipient County*
What county does the Care Recipient live in? Select from the list.
State
Zip Code*
Care Recipient Zip Code
Authorization for Release of Health Information

Required for us to coordinate with case management agency to start services
Date

MonthDayYear
Date
Hour MinutesAM/PM Option
Care Recipient Name:  {careRecipient}

Care Recipient Birthday:  {birthDate}

1. The purpose for this disclosure is to: Receive SFC services from Caring Hands United Inc.

2. The information to be disclosed is: Information related to approval for EDWP and/or SFC services.

3.    I understand that this authorization shall become effective immediately and shall remain in effect for one year from the date of signature if no date is entered.

I understand that I have the right to revoke this authorization, in writing, at any time, except where uses or disclosures have already been made based upon my original permission. I may not be able to revoke this authorization if its purpose was to obtain insurance. In order to revoke this authorization, I must do so in writing and send it to the appropriate disclosing party.

I understand that uses and disclosures already made based upon my original permission cannot be taken back. I understand that it is possible that information used or disclosed with my permission may be redisclosed by the recipient and is no longer protected by the HIPAA Privacy Standards.

I understand that treatment by any party may not be conditioned upon my signing of this authorization (unless treatment is sought only to create health information for a third party or to take part in a research study) and that I may have the right to refuse to sign this authorization.

I will receive a copy of this authorization after I have signed it. A copy of this authorization is as valid as the original.
Expiration Date for this Authorization (Optional)

MonthDayYear
Date
I hereby authorize EDWP case management agencies to disclose the medical information indicated below to CARING HANDS UNITED INC.

YesNo
Signature

Clear
Submitter Information
Are you completing this form on behalf of the person needing care / assistance?*

YesNo, I am the care recipient
Submitter Name

First NameLast Name
Relationship to Person Needing Assistance*

SelfHome Care ProviderFamily / RelativeFriendMedical ProfessionalOther Professional
Will you be the primary family caregiver for the care recipient?*

YesNo
Preferred Method of Contact*

PhoneEmailI do not wish to be contacted
Submitter Phone Number
Please enter a valid phone number.
Submitter Email
example@example.com
Is the person needing services aware that you are completing this form on their behalf?*

YesNo
Risk Assessment

If you wish to have Caring Hands United submit the request to your local agency, please fill out the questions below.
Is Alzheimer’s disease or cognitive impairment (such as increasing forgetfulness, difficulty understanding simple requests, etc…) suspected or diagnosed?*

YesNo
Does the person needing services live alone?*

YesNo
Does the person needing services live in a rural area?*

YesNo
Has the person needing services had any falls within the last 6 months?*

YesNo
Has the person needing services had any ER visits or hospitalizations within the last 6 months?*

YesNo
Has the person needing services had any Nursing Home/rehab stays within the last 12 months?*

YesNo
Is the person needing services below the poverty level and/or receiving any type of public assistance (Food Stamps/SNAP, TANF, LIHEAP, Medicaid, etc.)?*

YesNo
Is the person needing services an ethnic minority?*

YesNo
Does the person needing services require an English translator?*

YesNo
Does the person needing services need assistance with any of the following activities (select all that apply):*

EatingGroomingBathingDressingTransferring (ability to move around within the home)Continence (ability to control bowel/bladder function)
Is the person needing services a homeowner?*

YesNo
Additional notes or comments:
Enter any additional issues that are relevant to the care recipient's eligibility or care.
Family Caregiver Information
Family Caregiver Name
The name of the person who will serve as primary caregiver to the care recipient.
Case Manager Information

Medicaid Member's Case Manager info
Case Manager Name
What is the member's case manager's name?
Case Manager Phone Number
Please enter a valid phone number.
Case Manager's Email
example@example.com
SFC Eligibility
Is the caregiver the care recipient's parent or legal guardian?

YesNo
Is the caregiver the care recipient's spouse?

YesNo
How is the Caregiver related to the Care Recipient (Patient)?
Caregiver must be biologically or legally related to the care recipient
Is the caregiver the conservator or payee for the care recipient?

YesNo
Is the care recipient a minor (younger than 18 years old)?

YesNo
Is the caregiver 18 years old or older?

YesNo
Does the caregiver live in the same home as the care recipient?

YesNo
Would the caregiver pass a criminal background check (no disqualifying crimes committed or sentencing / parole within the past 10 years)?

YesNoNot sure
Acknowledgment*

By submitting this form, you agree to allow Caring Hands United Inc to verify the information that you provide, including information about consumer eligibility, and to contact you about your service inquiry.

See If Your Family Qualifies

EDWP Status

Care Recipient (Patient) Information

Authorization for Release of Health Information

Submitter Information

Risk Assessment

Family Caregiver Information

Case Manager Information

SFC Eligibility