Waiver Home Care Enrollment Form
Client Name
*
Client Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Client Gender
*
Male
Female
Client Marital Status
*
Single
Married
Divorced
Seperated
Widowed
Client Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Client Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Social Security Number
*
Medicare Number
Medicaid Number
Ohio Medicaid numbers are 12 digits
Emergency Contact Name
*
Emergency Contact Relationship
*
Please Select
Spouse
Child
Sibling
Step Child
Friend
Neighbor
Relative
Is the emergency contact the legal power of attorney for the client
*
Yes
No
Is the emergency contact the primary contact for this client
*
Yes
No
Emergency Contact Address
Street Address
Street Address Line 2
City
State
Zip
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Medical Diagnosis
If you do not know you diagnosis please put a short summary as to why you need home care
Recent Hospital or Nursing Facility Admission
*
Yes
No
Facility Name
Reason for admission
Admission Date
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Discharge/Expected Discharge Date
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Primary Physician
*
Physician Phone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Physician Address
*
Mailing Address
Street Address Line 2
City
State
Zip
Financial Determination
The following section will help determine the clients financial eligibility for this program
Clients Monthly Income
*
Please include SSI and other forms of income you may receive monthly
Spouses Monthly Income
*
Clients Assets (Bank Accts, Stocks, Bonds, CDs, Trusts, Cash Value Life Ins etc)
*
Please include the total amount in your bank account
*
Rows
Independent
Needs Supervision
Needs Hands on Assistance
Bed Mobility
Transfer
Locomotion
Bathing
Grooming
Toileting
Dressing
Eating
Medication
Shopping
Meal Prep
House Cleaning
Laundry
Telephoning
Transportation
Legal/Finance
I authorize BrightPath Home Care to
*
Act on my behalf in all matters with the agency [“agency” includes the County Department of Job and Family Services (CDJFS), the Ohio Department of Medicaid (ODM), and ODM’s contracted designees].
HIPPA Release
*
I authorize the protected health information related to homecare services to be realesd to BrightPath Home Care
Signature
Name of Applicant/Recipient
Medicaid Number or SSN
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name of Applicant/Recipient
Case Number/Medicaid ID
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
This PHI health information may be shared
This information is being released for the following purpose
Signature
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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