STANDARD PACKAGE – Ongoing Care Navigation Enrollment

STANDARD PACKAGE – Ongoing Care Navigation Enrollment

Enroll in monthly care navigation and advocacy services with Our Helping Hands (OHH) Health Solutions. Complete this form to initiate service, designate contacts, and authorize coordination.
SECTION 1: Service Recipient Information

Please provide details about the individual receiving care navigation services.
Full Name of Service Recipient*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Primary Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email Address*
example@example.com
Home Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Home AloneWith FamilyAssisted LivingOther
Primary Diagnoses or Health Conditions
YesNo
SECTION 2: Enrolling Party (If Different)

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

First NameLast Name
Relationship to Service Recipient
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: Primary Contact for Updates

Specify who should receive biweekly updates and your preferred communication method.
Service RecipientFamily CaregiverBothOther (please specify)
If 'Other', please provide name, phone, and email
EmailPhoneSecure messaging
SECTION 4: Billing & Payment Responsibility

Provide details for monthly billing and payment responsibility.
Service RecipientFamily MemberOther (please specify)
Email address for invoices*
example@example.com
Phone number for billing questions*
Please enter a valid phone number.Format: (000) 000-0000.
Monthly invoices will be sent to the email address on file. Payment is due on the same calendar date each month based on the initial enrollment date.
I understand this is a recurring monthly service at $850/month.
STANDARD PACKAGE – Ongoing Care Navigation (Subscription)
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Ongoing Care Navigation – Standard Package
Monthly care navigation and advocacy service. Includes up to 8 hours per month of direct patient advocacy support. $850 per month.

$850.00 for each month
SECTION 5: Care Navigation Needs

Select all care navigation services that are needed.
Appointment remindersAppointment scheduling or reschedulingInsurance issue assistanceAppeals supportCare plan developmentCoordination between providers/specialistsMedication tracking supportChronic condition monitoring supportOther
What are your top 3 concerns right now?
SECTION 6: Provider & Insurance Information

Provide details about primary care, specialists, and insurance.
Primary Care Provider Name*
Major Specialists (optional)
Insurance Company*
Member ID*
Upload Insurance Card (front & back)*

Cancelof
Upload any recent care plans or discharge summaries (optional)

Cancelof
SECTION 7: Authorization to Coordinate Care

Authorize OHH Health Solutions to coordinate care and communicate with third parties.
I authorize Our Helping Hands (OHH) Health Solutions to communicate with healthcare providers, specialists, facilities, and insurance companies on my behalf for the purpose of care navigation and advocacy.
I authorize OHH to coordinate care and insurance matters on my behalf.
SECTION 8: Service Scope & Monthly Terms

Review and acknowledge the terms of the STANDARD PACKAGE – Ongoing Care Navigation.
STANDARD PACKAGE – Ongoing Care Navigation

This service includes up to 8 hours per month of direct advocacy and care coordination support.

Included services may consist of:
• Appointment reminders and coordination
• Care plan creation and updates
• Assistance with insurance issues and appeals
• Coordination between providers and specialists
• Biweekly updates to designated family caregivers
• Priority phone or secure messaging support

Hours do not roll over to the next month.
Additional time beyond 8 hours may require an upgraded plan or additional agreement.
This service does not replace medical care or emergency services.
I understand this plan includes up to 8 hours per month
I understand unused hours do not roll over
I understand additional hours require a new agreement
I agree to the monthly service terms
SECTION 9: Electronic Signature

Sign electronically to complete enrollment.
Signature of Service Recipient or Authorized Representative*

Powered by Jotform SignClear
Date*

MonthDayYear
Date
Should be Empty:

STANDARD PACKAGE – Ongoing Care Navigation Enrollment

SECTION 1: Service Recipient Information

SECTION 2: Enrolling Party (If Different)

SECTION 3: Primary Contact for Updates

SECTION 4: Billing & Payment Responsibility

SECTION 5: Care Navigation Needs

SECTION 6: Provider & Insurance Information

SECTION 7: Authorization to Coordinate Care

SECTION 8: Service Scope & Monthly Terms

SECTION 9: Electronic Signature