Clone of LinkCo Client Service Request Form

Client Service Request Form

Questions? Business Office Hrs (Monday Thru Friday 9 am - 5pm EST) Please Call 1 (757) 802 - 4246 ext 2
Please Note: Service Requests Submitted Outside Our Normal Business Hours Monday thru Friday 9am - 5pm EST Will Be Reviewed The Next Business Day
Select request type*
Reason for change or cancellation*
Date of Original Requests*

MonthDayYear
Date
New Date (If Applicable)

MonthDayYear
Date
Time of Original Requests*

Hour Minutes

AM/PM Option
New Time (If Applicable)

Hour Minutes

AM/PM Option
Previous Pick-Up Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
New Pick-Up Address (If Applicable)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Previous Destination Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
New Destination Address (If Applicable) *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Additional comments or updates
Type a question
Name of person receiving services *

First NameLast Name
Care Receiver Name*

First NameLast Name
Name of person submitting this updated requests or cancellation*

First NameLast Name
Best contact number of person submitting this updated requests or cancellation*
Please enter a valid phone number.Format: (000) 000-0000.
Best Contact Number for mobility partner to Reach Client *
Format: (000) 000-0000.
How many service dates & times would you like to schedule?*
Pick Up Date 1 (Date Client Needs Service)*

MonthDayYear
Date
Pick up time 1 (Time Client Wants Driver to Arrive)*
Pick up Location or Service Address. *
Destination Address (if applicable)
Please indicate if this is for a roundtrip or one way requests.(put n/a if it does not apply)
Purpose of Service Request (Choose all that apply)*

Medical AppointmentOutpatient surgery or procedurePersonal Care AppointmentSocial/Recreational ActivityErrands and Grocery Shopping
Number of Service Hours Needed (mobility partners are not permitted to go over time limit)*
Pick Up Date 2 (Date Client Needs Service)*

MonthDayYear
Date
Pick up time 2 (Time Client Wants Driver to Arrive)*
Pick up Location or Service Address. *
Destination Address (if applicable)
Please indicate if this is for a roundtrip or one way requests.(put n/a if it does not apply)
Purpose of Service Request (Choose all that apply)*

Medical AppointmentOutpatient surgery or procedurePersonal Care AppointmentSocial/Recreational ActivityErrands and Grocery Shopping
Number of Service Hours Needed (mobility partners are not permitted to go over time limit)*
Pick Up Date 3 (Date Client Needs Service)*

MonthDayYear
Date
Pick up time 3 (Time Client Wants Driver to Arrive)*
Pick up Location or Service Address. *
Destination Address (if applicable)
Please indicate if this is for a roundtrip or one way requests.(put n/a if it does not apply)
Purpose of Service Request (Choose all that apply)*

Medical AppointmentOutpatient surgery or procedurePersonal Care AppointmentSocial/Recreational ActivityErrands and Grocery Shopping
Number of Service Hours Needed (mobility partners are not permitted to go over time limit)*
Pick Up Date 4 (Date Client Needs Service)*

MonthDayYear
Date
Pick up time 4 (Time Client Wants Driver to Arrive)*
Pick up Location or Service Address. *
Destination Address (if applicable)
Please indicate if this is for a roundtrip or one way requests.(put n/a if it does not apply)
Purpose of Service Request (Choose all that apply)*

Medical AppointmentOutpatient surgery or procedurePersonal Care AppointmentSocial/Recreational ActivityErrands and Grocery Shopping
Number of Service Hours Needed (mobility partners are not permitted to go over time limit)*
Pick Up Date 5 (Date Client Needs Service)*

MonthDayYear
Date
Pick up time 5 (Time Client Wants Driver to Arrive)*
Pick up Location or Service Address. *
Destination Address (if applicable)
Please indicate if this is for a roundtrip or one way requests.(put n/a if it does not apply)
Purpose of Service Request (Choose all that apply)*

Medical AppointmentOutpatient surgery or procedurePersonal Care AppointmentSocial/Recreational ActivityErrands and Grocery Shopping
Number of Service Hours Needed (mobility partners are not permitted to go over time limit)*
Select your Membership Level*

Basic MembershipPremier MembershipElite Membership
Basic Membership: Scheduling: confirmation within 3–5 days of each request Mobility Care Partner: assigned based on availability (same person not guaranteed) Booking Fee: applies to any service requests made by phone; no fee for online scheduling

Basic Members MUST schedule services for the actual number of hours needed to ensure appropriate caregiver matching and availability. We no longer a lot for time to run over as it impacts the next clients ability to receive services as scheduled.

Premier Membership: Priority scheduling within 48 hours. MUST schedule services for the actual number of hours needed to ensure appropriate caregiver matching and availability. We no longer a lot for time to run over as it impacts the next client’s ability to receive services as scheduled.

Elite Membership: Priority scheduling. Guaranteed caregiver continuity with a dedicated care team
Name of person submitting this request: *
Notes
Acknowledgement of terms and conditions:*

Payment and Termination of Services: Payment is due at the time services have been rendered unless other arrangements have been made. Therefore, we reserve the right to suspend or discontinue services for non-payment of an account balance. You acknowledge that a valid credit card must always remain on file unless other arrangements have been made. Failure todo may result in your account being deactivated at our discretion. Service Charges: Hourly service charges are billed separately based on the actual hours used, subject to the plan’s minimum service requirements. Outpatient Procedures: For Basic and Premier Plan Members, all outpatient procedure appointments are automatically scheduled for a minimum of 4 hours to allow sufficient time for transportation, waiting periods, and safe return home.Acknowledgement of Appropriateness of Services:Please acknowledge that you can sit, walk and stand with minimal assistance and understand LinkCo health workers cannot carry or lift clients and do not provide personal care services, which include but not limited to bathing, grooming, toileting, dressing or feeding. Clients that are wheelchair bound must be able to self-transfer in and out of a non-wheelchair accessible vehicle using a transfer board or other equipment that can be stowed away safely in a regular vehicle during transport. Submission of this form does not guarantee we can provide services on the date and/or time you’ve requested. A member of the scheduling team will send out notification to confirm or decline your request.
You acknowledge that requests made with 24 hours or less notice will be assessed a surcharge in the amount of $85 in addition to regular service fees charged for billable hours. To avoid this surcharge all service requests must be received Monday thru Friday during our business office hours of 9 am to5pm est.
We do not guarantee that your preferred health worker will be available upon request as they are scheduled based on their availability.
Medical Equipment and Devices Please acknowledge that if you have a wheelchair, walker or rollator you understand these items must be collapsible and able to be stowed away safely in a non-wheelchair accessible vehicle such as a sedan, SUV or minivan.Cancellation Fee and Policy A cancellation fee of $55 will be charged for all scheduled appointments not cancelled at least 1 business day before the scheduled appointment.
Type a question
Should be Empty: