Intercommunity Home Health Care

Today’s Date:*

MonthDayYear
Date
INDIVIDUAL’S INFORMATION
Name*

First NameLast Name
Date of birth*

MonthDayYear
Date
Sex*

MaleFemale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
County*
Are Medical Assistance and the waiver currently active?*

YesNo
What is the renewal date: *

MonthDayYear
Date
Select Services Type*

Adult companion servicesHome making servicesNight supervisionRespite care in and outICLSIHS with and with out trainingCFSS
Insurance*

Blue Cross Blue ShieldUcareMedicamedical assistant
When would you like to start services? *

MonthDayYear
Date
Guardianship status*

SelfOther (list name and contact info)
CFSS Participant Representative*

SelfOther
CASE MANAGER INFORMATION

Intercommunity Home Health Care values the presence, support and input of case managers on the support team. We ask that case managers coordinate and attend the intake meeting of the person being referred. Ensuring the best coordination possible for people taking the step towards full community integration is our goal.
Case Manager Name: *

First NameLast Name
Phone Number*
Please enter a valid phone number.
County/Agency*
Email
example@example.com
Fax*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Attach any supporting documents to help us process your referral.

Cancelof
Should be Empty:

INDIVIDUAL’S INFORMATION