Long Term Care Services and Supports
Cathy Home Care Dallas Initial Screening and Intake
Applicant Information
State ID
County ID
Name
*
Mr.
Mrs.
Prefix
First Name
Middle Name
Last Name
Primary Language
Please Select
English
Vietnamese
Spanish
Chinese
Lao
Cambodia Khmer
Date of Birth
*
-
Month
-
Day
Year
Date
Social Security Number
Marital Status
Single
Married
Divorced
Widowed
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Physical Address (current location of applicant)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Identification Verification Document Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Authorized Representative / Legal Guardian Information
Representative/Guardian Name
First Name
Last Name
Relationship
Email
example@example.com
1st Phone Number
Please enter a valid phone number.
2nd Phone Number
Please enter a valid phone number.
Preferred method of contact
Email
Phone
Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Further Applicant Information
Urgent?
Current Living Situation
Alone
With Parents
Adult Foster Care
With Non-Relatives
With Spouse/Others
With Non-Spouse Relatives
DD Residential Program
Hospital Discharge
Assisted Living / Alternative Care Facility
Nursing Facility
ICF/MR
Pending Nursing Facility Discharge or Admission
Is there another person in the household who is also applying for -- or currently receiving -- Long Term Care Medicaid services?
Yes
No
Presenting Problems and Diagnoses
Desciption
Areas of Concern
Bathing
Dressing
Eating
Toileting
Transferring
Mobility
Behaviors
Possible Mental Illness
Memory/Cognition
Possible Developmental Disability
Brain Injury
Waiver Options
Brain Injury Waiver (BI)
Community Mental Health Supports Waiver (CMHS)
Complementary and Integrative Health Waiver (CIH)
Developmental Disabilities Waiver (DD)
Elderly, Blind and Disabled Waiver (EBD)
Supported Living Services Waiver (SLS)
Children with Life Limiting Illness Waiver (CLLI)
Children's Extensive Support Waiver (CES)
Children's Habilitation Residential Program Waiver (CHRP)
Children's Home and Community Based Services Waiver (CHCBS)
Non-Waiver Program Options
Home Care Allowance (HCA)
The Programs of All-Inclusive Care for the Elderly (PACE)
Family Support Services Program (FSSP)
Nursing Facility
State-Supported Living Services
Omnibus Reconciliation Act of 1987 (OBRA)
Other Residence?
Other
Insurance Information
Client's Insurance Information
United Healthcare
Molina Healthcare
Community Health Choice
Texas DADS
Amerigroup
Medicaid
Medicaid Pending?
Comments
Medical Provider Information
Professional Medical Information Page Sent To Provider?
Provider Name
Type of Provider
Provider Phone Number
Please enter a valid phone number.
Provider Fax Number
Please enter a valid fax number.
Provider Email
example@example.com
Provider Contact
example@example.com
Provider Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Comments
Authorization for Disclosure of Protected Heatlh Information (PHI)
Cathy Home Care LTD. (DBA Cathy Home Care)
To support the coordination and delivery of home care services and related medical supplies, I authorize my healthcare providers—including but not limited to physicians, hospitals, pharmacies, medical equipment suppliers, home health agencies, caregivers, insurers, and social service agencies (including behavioral or mental health providers)—to disclose my Protected Health Information (PHI), such as medical records, treatment plans, and billing information, to Cathy Home Care LTD. (DBA Cathy Home Care), its employees, and business associates operating under a HIPAA-compliant Business Associate Agreement (BAA), including third-party IT services used for data entry and processing of this authorization form. This information may be used by Cathy Home Care for the purposes of evaluating my service needs, confirming my eligibility for services or products, arranging or managing services and products, coordinating with third parties such as insurance providers or public benefit programs, and processing this authorization form through secure IT systems to ensure appropriate support and continuity of care. I also permit Cathy Home Care to discuss my care, treatment, and service arrangements with the healthcare providers and agencies listed above, as necessary to facilitate my care. If applicable, my PHI may be shared with the following individual(s) whom I have designated:
Name of Designated Individual (Leave Blank if There Is None)
First Name
Middle Name
Last Name
I understand that: -I have the right to revoke this authorization in writing at any time by sending a written notice to the main office of Cathy Home Care at 7601 W Sam Houston Pkwy S, Suite 818, Houston, TX 77072. Revocation will not affect actions already taken in reliance on this authorization. - Information disclosed under this authorization may be subject to further disclosure by the recipient as permitted or required by law and may no longer be protected by HIPAA. - Cathy Home Care will not condition the provision of treatment, payment, enrollment, or eligibility for benefits on signing this authorization, except as permitted by law (e.g., for eligibility determinations). - This authorization complies with applicable Texas state laws; contact Cathy Home Care for state-specific details. This authorization will remain in effect until revoked in writing by me or terminated in writing by Cathy Home Care.
Signature
Date
-
Month
-
Day
Year
Date
Name
First Name
Middle Name
Last Name
A COPY CAN BE PROVIDED TO THE PERSON SIGNING THIS AUTHORIZATION UPON REQUEST.
Client or Representative Signature
I certify that the accompanying information accurately reflects information given by me or on my behalf on the date specified. I understand that this information is used as a basis for scheduling an assessment and agree to be assessed for all Medicaid Long Term Care benefits administered by the above agency.
Client or Representative Signature
SUMMIT
SUMMIT
Should be Empty: