New MexiCare - Caregiver Health Program Application

Applicant Name

First NameLast Name

Applicant's Physical Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Applicant's Date of Birth

Date

County where applicant resides

Applicant's Phone Number

Please enter a valid phone number.

Applicant's Email

example@example.com

Applicant SSN

Applicant's Monthly Net Income

Include all sources of income, social security, retirement, pensions, etc. - [net means after tax amount of all sources]

Source of income (select all that apply)

Social SecurityRetirementPensionsOther

Is Applicant married?

YesNo

Does Applicant have a checking account?

YesNo

Does Applicant have a savings account?

YesNo

Does Applicant have an authorized representative?

YesNo

If yes, what is the name of Authorized Representative?

Does Applicant need assistance with two or more of the following? Please refer to the Assessment Scale below.

	0	1	2	3	4	5	6	7	8
Bathing
Dressing/Grooming
Eating
Preparing/Acquiring Meals
Transferring
Ambulation
Toileting
Bowel/Bladder
Handling Medication

Other assistance needs.

Assessment Scale:

0-INDEPENDENTLY: No support from devices/caregiver and has no difficulty completing the activity.

1-ALONE WITH DIFFICULTY: Can perform alone, but may have expressed some concerns performing or having difficulty perform alone.

2-SOMETIMES NEEDS MONITORIING/ASSISTED DEVICES: Can perform activity but caregiver or assistive device is available.

3- ABLE, BUT UNWILLING: Demonstrates the ability to perform activity but has voiced unwillingness to perform.

4-FREQUENTLY NEEDS ASSISTANCE: Caregiver or assistive device is readily available and frequently used in order to perform.

5- ALWAYS NEEDS ASSISTANCE: Does not/cannot perform without caregiver or assistive device.

6- ALWAYS NEEDS ASSISTANCE BUT INADEQUATE OR NO CAREGIVER AVAILABLE: Demonstrated need for assistance and does not have access to proper assistive devices or caregiver.

7-UNABLE TO DETERMINE: More information needs to be gathered in order to provide a proper assessment score.

8- UNABLE TO PERFORM: Does not have the ability to perform, this goes beyond the use of needing assistive devices or caregiver. This would pertain to an individual that has no leg mobility, paralysis, or other condition that significantly impedes to perform this activity even with proper assistance.

Please check the box for covered services the Applicant is interested in.

Personal Care/Homecare Services – To assist the participant with Activities of Daily Living (ADLs)Daycare (Agency Based) - Provides adult daycare to vulnerable, functionally impaired adults in an organized, structured program that includes therapeutic services and activities designed to serve adults whose disabilities impair his/her ability to pursue ADLs.Respite - Is used to give the primary caregiver a break on an episodic basis in the event of an emergency or to prevent burnout.Transportation - Transportation services are offered to enable participants in order to gain access to appointments, community services, and other activities.Prescription Medication Co-Pays and Deductibles - A participant may utilize funding from the Goods & Services allotment to pay for co-pays or deductibles for prescription medications not covered by their insurance plan or Medicare.Chore Services - Clients may require assistance with a one-time or short-term chore service in their home if it is impacting their health and safety.Home, Health, & Safety Monitoring & Equipment - Includes the purchase and/or installation of equipment and/or physical adaptations to a participant’s residence that are necessary to ensure the health and safety of the participant or enhance the participant’s level of independence.

Does the applicant need transportation to and from health appointments, stores, or community events?

YesNoUnsure

Number of adult protective service investigations within the last 24 months (documentation may be requested during in-home assessment)

01-23 or moreUnknown

Number of hospitalizations in the 12 months

01-23 or more

Number of visits to the emergency room in the last 12 months

01-23 or more

Do any of the following pertain to the Applicant?

Applicant is raising a grandchild (grandchild is under the age of 18 lives with applicant and is reliant on applicant for care)Applicant cares for an adult who has an intellectual or developmental disabilityApplicant is homeboundApplicant is bedbound

Please identify all medical diagnoses for the applicant, if none, indicate N/A

New MexiCare - Caregiver Health Program Application

Applicant (Person Needing Assistance)

Level of Care Criteria

Assessment Scale:

Caregiver Information

At what frequency does the applicant need support with the following?

How many hours per week for each activity does the applicant receive help from the caregiver?

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