Vital Health Home Care — Care Assessment & Service Request

Vital Health Home Care — Care Assessment & Service Request

Submit a secure home care request for review—include only necessary information and do not use this form for emergencies.
Person completing form
Relationship to the person needing care

Other
Legal authority details
Submitter full name

First NameLast Name
Phone number
Please enter a valid phone number.Format: (000) 000-0000.
Email address
example@example.com
Person needing care
Full legal name

First NameMiddle NameLast Name
Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Street address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
County
Phone number
Please enter a valid phone number.Format: (000) 000-0000.
Preferred language
Accessibility or communication needs
Services requested
Requested services

Other
Details of activities of daily living assistance needed
Respite care schedule and preferred coverage times
CAP program details
Case manager name
Case manager phone number
Please enter a valid phone number.Format: (000) 000-0000.
Prescriber or physician order information
Requested skilled nursing tasks
Care needs and schedule
Days care is needed
Preferred care start time

Hour Minutes

AM/PM Option
Preferred care end time

Hour Minutes

AM/PM Option
Preferred care start date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Current living arrangement
Mobility and transfer assistance needed

Other
Fall risk
Allergies or sensitivities
Infection-control or isolation concerns

Other
Behavioral, safety, or home access considerations
Pets or smoking in the home
Equipment used in the home

Other
Additional care details
Payment pathway
Payment / coverage pathway
Insurance / member ID
Plan name
Case manager name
Organization
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Fax
Please enter a valid phone number.Format: (000) 000-0000.
Authorization status
Current providers and discharge information
Primary clinician name

First NameMiddle NameLast Name
Hospital or facility name
Discharge date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Care coordinator name

First NameMiddle NameLast Name
Consent and attestation
I authorize Vital Health to contact me regarding this request

Other
I authorize Vital Health to verify benefits and obtain service authorization as needed
I authorize communication with listed providers and case managers for care coordination
Notice of Privacy Practices
Typed signature (full legal name)

First NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Secure document uploads

Upload any supporting documents that help us review this request.
Insurance card

Front and back, if available.
Cancelof
Authorization or service plan

Upload any current authorization or service plan document.
Cancelof
Physician order

Upload the most recent order, if available.
Cancelof
Discharge documents

Discharge summary or related records.
Cancelof
Nursing plan

Care plan, visit plan, or similar documents.
Cancelof
Other supporting records

Any other documents that may help with review.
Cancelof
I certify that the information provided is accurate and complete to the best of my knowledge.
Should be Empty:

Vital Health Home Care — Care Assessment & Service Request

Person completing form

Person needing care

Services requested

Care needs and schedule

Payment pathway

Current providers and discharge information

Consent and attestation

Secure document uploads