Online Service Request

Service Request
Client Information
If the client is a minor, please note that a parent or legal guardian must complete this form. Parents cannot be paid caregivers for their own children under Medicaid rules.
Client Name*

First NameLast Name
Client Date of Birth*

MonthDayYear
Date
Age
calc
CurrentDate

MonthDayYear
Date
Parents/Legal Guardian*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com

Caregiver
Do you already have a caregiver you would like our agency to hire and train?*

Yes, I have someone in mindNo, I do not have a caregiver yet
Important Notice:
Our agency follows a client-directed model in which the client identifies a caregiver they would like to work with. We hire and train the caregiver of your choice.

If you do not have someone in mind, you may still submit your request. However, please note that we cannot guarantee that a caregiver will be assigned to you through our agency.
Would you like to continue with the service request?*

Yes, I would like to continue with the understanding aboveNo, I do not have a caregiver and prefer not to continue
What is the caregiver's relationship to the client?*

ParentOther RelativeNeighbor/Friend
Notice: Under Medicaid rules, parents cannot be paid caregivers for their own minor children. You may still complete this form, but your selected caregiver will not be eligible for compensation.
Thank you for your time and interest in our services. You may now close your browser window to exit this form.

Caregiver Contact (Optional)
If you have identified a preferred caregiver, we can send them a secure link to complete our caregiver application and required background check. Please provide their full name and contact information below.
Caregiver Email
example@example.com
Caregiver Name

First NameLast Name
Caregiver Phone Number
Please enter a valid phone number.

Current Services
Is the client currently receiving services from a personal care agency*

YesNo
Clients can only be enrolled in one PCW agency at a time. Will the client be switching agencies?

YesNo
Important Notice:
Medicaid policy does not allow members to receive personal care services from more than one agency at the same time. If you are not switching from your current agency, we are unable to proceed with your request for services.

Physician
In order to begin services, Medicaid requires a referral or order from your primary care provider. We can assist by contacting your doctor to request this documentation if you prefer.
Would you like us to send a referral request to your primary care physician at this time?

Yes, please send the request on my behalfNo, I will handle the referral myself
Client's Primary MD*

First NameLast Name
Primary MD Phone*
Please enter a valid phone number.
I authorize Supportive Personal Care Services, LLC to contact my doctor to request a referral or order for personal care services.

Parental Consent & Acknowledgment Statement
Consent & Acknowledgment Statement
I acknowledge that I am the parent or legal guardian of the minor named in this form. I understand and consent to the provision of in-home care services for my child. I further acknowledge that, under Medicaid program rules, I cannot be paid as a caregiver to provide personal care or supportive home care services to my own child.

I consent to be contacted for further assessment and understand that eligibility for services will be determined based on program requirements.
I confirm that I am requesting in-home care services for myself and that the information provided in this form is true and complete to the best of my knowledge. I consent to be contacted for further assessment and understand that eligibility for services will be determined based on program requirements.
Signature*

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Service Request