Anchor Healthcare

Anchor Healthcare

In-Home Pediatric Care
New Client Intake Packet (GAPP)
Peachtree Family Services provides in-home care and support services for children with medical or developmental needs. Please complete this intake form so our team can review your child’s information and begin the eligibility and assessment process.

1. Client Intake Form
Child's Full Name:
Date of Birth:

MonthDayYear
Date
Medicaid ID Number:
Gender:
Home Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Language Spoken at Home:
School Name (if applicable):

Does the child have an IEP?
Yes / No
Diagnosis (if known):
Primary Care Physician Name:
Physician Phone Number:
Format: (000) 000-0000.
Physician Address:
Specialists involved in care (if applicable):
2. Parent / Guardian Information
Primary Caregiver Name:
Relationship to Child:

Phone Number:
Format: (000) 000-0000.
Email Address:
example@example.com
Home Address (if different from child):
Employer (optional):
Emergency Contact Name:
Emergency Contact Phone:
Format: (000) 000-0000.
3. Insurance Information
Primary Insurance:
Georgia Medicaid
Medicaid ID:

Secondary Insurance (if applicable):
Insurance Phone Number:
Format: (000) 000-0000.
4. Medical History Summary
Please list any of the following that apply:
Medical Conditions
Other medical conditions:

Has the child been hospitalized in the last 12 months?
If yes, please explain:
5. Current Medications
Medication Name | Dosage | Frequency | Purpose
Medication 1:
Medication 2:
Medication 3:

8. Medical Equipment Used
Does the child use any of the following?
Other equipment used:
9. Physician Information Authorization

Primary Care Physician:
Name:
Address:
Phone:
Format: (000) 000-0000.
Fax:
Specialists:
Name:
Specialty:
Phone:
Format: (000) 000-0000.

10. HIPAA Medical ReleaseAuthorization
I authorize Anchor Healthcare to obtain medical records related to my child's diagnosis and treatment from physicians, hospitals, therapists, and other healthcare providers for the purpose of determining eligibility and coordinating care services.
Parent / Guardian Name:
Signature:
Date:

11. Freedom of Choice Statement
I understand that I have the right to choose any qualified provider for services. I voluntarily choose Anchor Healthcare to provide services for my child.
Parent / Guardian Name:
Signature:
Date:

MonthDayYear
Date

12. Letter of Understanding
I understand that:
- services must be approved by Medicaid before they begin
- caregivers will provide assistance according to the care plan
- documentation may be required to maintain services.
Parent / Guardian Signature:
Date:

MonthDayYear
Date

13. Parent Consent for Assessment
I authorize Anchor Healthcare to conduct a nursing assessment for my child to determine eligibility for services.
Parent / Guardian Signature:
Date:

MonthDayYear
Date
Should be Empty: