• 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?*

  • 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?*

  • 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?*
  • Is (or was) the care recipient already approved for Structured Family Caregiver or other home care services?*
  • Does the Medicaid Member (Care Recipient) have a cost share?*
  • 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.*
  • 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.*
  • Would you like for us to check whether the care recipient is already eligible for EDWP services?*
  • 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?*
  • Is the Care Recipient's gross income $943/month or less?*
  • Is the Care Recipient's monthly income from all sources of income $2,829 or less?*

  • 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?*

  • Care Recipient (Patient) Information

    This section pertains to the person needing care / services.
  • Birth Date*
     / /
  • Gender*

  • Authorization for Release of Health Information

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

  • 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)
     - -
  • I hereby authorize EDWP case management agencies to disclose the medical information indicated below to CARING HANDS UNITED INC.

  • Submitter Information

  • Are you completing this form on behalf of the person needing care / assistance?*
  • Relationship to Person Needing Assistance*
  • Will you be the primary family caregiver for the care recipient?*
  • Preferred Method of Contact*
  • Format: (000) 000-0000.
  • Is the person needing services aware that you are completing this form on their behalf?*

  • 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?*
  • Does the person needing services live alone?*
  • Does the person needing services live in a rural area?*
  • Has the person needing services had any falls within the last 6 months?*
  • Has the person needing services had any ER visits or hospitalizations within the last 6 months?*
  • Has the person needing services had any Nursing Home/rehab stays within the last 12 months?*
  • Is the person needing services below the poverty level and/or receiving any type of public assistance (Food Stamps/SNAP, TANF, LIHEAP, Medicaid, etc.)?*
  • Is the person needing services an ethnic minority?*
  • Does the person needing services require an English translator?*
  • Does the person needing services need assistance with any of the following activities (select all that apply):*
  • Is the person needing services a homeowner?*

  • Family Caregiver Information

  • Case Manager Information

    Medicaid Member's Case Manager info
  • Format: (000) 000-0000.

  • SFC Eligibility

  • Is the caregiver the care recipient's parent or legal guardian?
  • Is the caregiver the care recipient's spouse?
  • Is the caregiver the conservator or payee for the care recipient?
  • Is the care recipient a minor (younger than 18 years old)?
  • Is the care recipient at least 21 years old?
  • Is the caregiver 18 years old or older?
  • Does the caregiver live in the same home as the care recipient?
  • Would the caregiver pass a criminal background check (no disqualifying crimes committed or sentencing / parole within the past 10 years)?
    • View Financial Eligibility for Program Participation 

    • The following income/financial requirements apply to the patient (Medicaid "Member") who requires care.

      Gross income includes all income sources, such as Social Security, Pension Benefits, Annuity Payments, employment income, royalties, etc… 

      Income cannot exceed $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.

      For individuals whose gross income is above the current SSI limits ($943/month), there may be a cost share for services. The estimated cost share can be calculated by subtracting $943 from the gross monthly income (example: SSA income is $1,143 per month; after subtracting $943, the estimated monthly cost share for EDWP services would be $200). 

      • Some adjustments may be made to reduce cost share, including “spousal diversion” for individuals who are married and only one of the couple is participating in a Medicaid program.

      Assets/Resources are limited to $2,000 for an individual. This includes stocks, bonds, savings accounts, certificates of deposit, second homeplace, second automobile, property not connected to the primary homeplace, etc.

      There is a five-year lookback period for transfer of assets. Individuals who have transferred assets or property to another individual in the last five years may be subject to a period of disqualification for Medicaid waiver programs. This period of disqualification is based upon the value of the transfer and the date upon which the transfer occurred. You may still be eligible for services even if you have recently transferred assets to someone else.

      Program participants must meet a nursing home level of care. This does not mean that applicants must currently reside in a nursing home. It simply means that the applicant’s need for care must be consistent with those who are eligible to receive Medicaid care in a nursing home (typically 5+ hours or care needed daily).

    • View Caregiver Eligibility for Program Participation 

    • The following requirements apply to family caregivers under this program:

      Caregiver must be biologically or legally related to the care recipient. A spouse, legal guardian, parent of a minor child or conservator is not eligible to be the structured family caregiver.

      The family caregiver must reside in the same home with the individual receiving care. Living next door or across down does not meet the eligibility criteria.

      The family caregiver is not allowed to have any other means of employment. Individuals who receive a caregiver stipend for structed family caregiver services are not allowed to have any other means of employment either in the home or outside the home, including owning/operating their own business or teleworking for another employer.

      Additionally:

      • The structured family caregiver must be at least 18 years of age
      • Caregiver must pass a criminal background check
      • Tasks must be recorded every day (electronically)
      • Monthly contact with Health Coach

      Individuals receiving Structured Family Caregiver are not eligible for the following services under the EDWP program:

      • Medicaid Home Care Services from another provider
      • Home Delivered Meals
      • A Stipend payment for days when the Member is in a hospital, nursing facility, or other institution.
    • Should be Empty: