Companion Call Service Enrollment
Official enrollment form for Our Helping Hands (OHH) Health Solutions Companion Call Service. Please complete all sections to begin services.
SECTION 1: SERVICE RECIPIENT INFORMATION
Who the companion calls are for
Full Name of Service Recipient
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number to Receive Calls
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Call Days
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Preferred Call Time Window
*
Any hearing, cognitive, or communication considerations we should be aware of?
Living Situation
*
Home alone
With family
Assisted living
Other
SECTION 2: PRIMARY CONTACT PERSON
Who OHH should communicate with
Are you the service recipient or someone enrolling on their behalf?
*
Service Recipient
Family Member
Caregiver
Other
Full Name of Primary Contact
*
First Name
Last Name
Relationship to Service Recipient
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Preferred Method of Communication
*
Phone
Email
SECTION 3: BILLING & PAYMENT RESPONSIBILITY
This section must clearly establish who is paying
Who is financially responsible for this service?
*
Service Recipient
Family Member
Other
Full Name of Person Responsible for Payment (if different from primary contact)
First Name
Last Name
Email Address for Invoices (if different from primary contact)
example@example.com
Phone Number (if different from primary contact)
Please enter a valid phone number.
Format: (000) 000-0000.
I understand that invoices and payment notices will be sent to the email address provided above.
*
I understand that invoices and payment notices will be sent to the email address provided above.
SECTION 4: SERVICE SELECTION
Select your Companion Call plan
Which Companion Call option are you enrolling in?
*
Weekly Calls
Bi-Weekly Calls
Monthly Calls
Start Date for Service
*
-
Month
-
Day
Year
Date
Clients enrolled in a monthly plan will receive an invoice by email 5 days before the payment due date. The due date will be the same calendar date as the first payment made today.
I understand the monthly billing and invoice schedule described above.
*
I understand the monthly billing and invoice schedule described above.
SECTION 5: GOALS & PREFERENCES FOR COMPANION CALLS
Personalize your experience
What is the primary goal of these companion calls? (check all that apply)
*
Social connection
Emotional support
Routine check-ins
Accountability
Other
Topics the service recipient enjoys talking about
*
Topics to avoid (optional)
SECTION 6: EMERGENCY & BACKUP CONTACT
For safety and backup communication
Emergency Contact Name
*
First Name
Last Name
Relationship
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Companion Calls are non-medical and not an emergency service.
SECTION 7: SHORT SERVICE AGREEMENT & ACKNOWLEDGMENTS
Please review and acknowledge the following
Companion Call Service Agreement
I understand that Companion Calls provided by Our Helping Hands (OHH) Health Solutions are non-clinical, non-medical social support services.
I understand that this service does not replace medical care, emergency services, or crisis intervention.
I understand that scheduling is based on availability and agreed-upon call frequency.
I understand that for monthly plans, invoices will be sent 5 days prior to the due date, and the due date will align with the date of the first payment made.
I agree to the Companion Call Service terms
*
I agree to the Companion Call Service terms
I confirm the billing and payment responsibility information is accurate
*
I confirm the billing and payment responsibility information is accurate
SECTION 8: ELECTRONIC SIGNATURE
Signature of Service Recipient or Authorized Representative
Signature of Service Recipient or Authorized Representative
*
Date
*
-
Month
-
Day
Year
Date
Submit Enrollment
Submit Enrollment
Should be Empty: