ESSENTIALS PACKAGE – Peace of Mind Support Enrollment

ESSENTIALS PACKAGE – Peace of Mind Support Enrollment

Enroll in the ESSENTIALS PACKAGE – Peace of Mind Support. Complete this form to secure your 3-hour prepaid patient advocacy package with Our Helping Hands (OHH) Health Solutions.
SECTION 1: SERVICE RECIPIENT INFORMATION

Please provide details for the person who will receive support.
Full Name of Person Receiving Support*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email Address*
example@example.com
HomeWith FamilyAssisted LivingOther
SECTION 2: ENROLLING PARTY (If Different)

Complete this section if you are enrolling someone other than yourself.
SelfFamily MemberCaregiverOther
Your Full Name (if enrolling someone else)

First NameLast Name
Relationship to Service Recipient (if enrolling someone else)
Phone Number (if enrolling someone else)
Please enter a valid phone number.Format: (000) 000-0000.
Email Address (if enrolling someone else)
example@example.com
SECTION 3: BILLING & PAYMENT RESPONSIBILITY

Clarifies who is paying and where invoices go.
Service RecipientFamily MemberOther (please specify)
Email Address for Payment Confirmation and Receipts*
example@example.com
I understand this package is a prepaid 3-hour service totaling $375.
ESSENTIALS PACKAGE – Peace of Mind Support (3-Hour Patient Advocacy Package)
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ESSENTIALS PACKAGE – Peace of Mind Support
Prepaid 3-hour personalized patient advocacy support package. Services to be used within 30 days of purchase.

$375.00

Total

$0.00
SECTION 4: WHAT SUPPORT IS NEEDED

Select all areas where support is needed.
Medical bill and insurance reviewScheduling and coordination of up to 2 appointmentsMedication organization supportMedical record organizationGeneral healthcare navigation questionsOther (please specify)
What is the main goal you would like to accomplish with this package?*
SECTION 5: APPOINTMENT & COORDINATION DETAILS (If Applicable)

Complete this section if you need help scheduling or rescheduling appointments.
YesNo
Provider name(s) (if yes)
Preferred dates/times (if yes)
Any deadlines? (if yes)
SECTION 6: FAMILY CHECK-IN CALL

Provide details for the 15-minute family check-in call.
Name of family member for 15-minute check-in call
Preferred contact number
Please enter a valid phone number.Format: (000) 000-0000.
Preferred time of day
SECTION 7: COMMUNICATION PREFERENCES

Tell us how you prefer to communicate.
EmailPhone
Best days/times for communication
Secure email support is available during the active 30-day service period.
SECTION 8: PACKAGE TERMS & SERVICE AGREEMENT

Please review the package details and acknowledge the terms below.
ESSENTIALS PACKAGE – Peace of Mind Support

This package includes up to 3 hours of personalized patient advocacy services to be used within 30 days of purchase.

Included services may consist of:
• Medical bill and insurance review
• Scheduling and coordination of up to 2 appointments
• Medication and record organization
• One 15-minute family check-in call
• Secure email support during the active service period

Services beyond 3 hours or outside the 30-day period require a new agreement.

This package does not include direct insurance appeals, extended negotiations, emergency services, or ongoing representation unless separately contracted.
I understand this package includes up to 3 hours of service
I understand services must be used within 30 days
I understand additional time requires a new agreement
I agree to the terms of the ESSENTIALS PACKAGE
SECTION 9: ELECTRONIC SIGNATURE

Please sign to confirm enrollment and agreement.
Signature of Client or Authorized Representative*

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Date*

MonthDayYear
Date
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ESSENTIALS PACKAGE – Peace of Mind Support Enrollment

SECTION 1: SERVICE RECIPIENT INFORMATION

SECTION 2: ENROLLING PARTY (If Different)

SECTION 3: BILLING & PAYMENT RESPONSIBILITY

SECTION 4: WHAT SUPPORT IS NEEDED

SECTION 5: APPOINTMENT & COORDINATION DETAILS (If Applicable)

SECTION 6: FAMILY CHECK-IN CALL

SECTION 7: COMMUNICATION PREFERENCES

SECTION 8: PACKAGE TERMS & SERVICE AGREEMENT

SECTION 9: ELECTRONIC SIGNATURE