PLEASE NOTE:
THIS INFORMATION IS BEING COLLECTED FOR THE PURPOSE OF FACILITATING YOUR APPLICATION FOR ATTENDANT SERVICES AND SHALL ONLY BE RELEASED IN ACCORDANCE WITH THE TERMS SET OUT IN THIS APPLICATION OR AS PEEL CHESHIRE HOMES MAY BE REQUIRED BY LAW.
PLEASE CHECK (√) AND MAKE SURE YOU MEET THE FOLLOWING ELIGIBILITY REQUIREMENTS BEFORE YOU COMPLETE THE APPLICATION.
IF YOU DO NOT MEET THE ABOVE ELIGIBILITY REQUIREMENTS, YOUR APPLICATION FOR ATTENDANT SERVICES WILL NOT BE ACCEPTED AND WILL BE RETURNED.
Select ONE main permanent physical disability that requires you to use attendant services ( Do NOT choose more than ONE. List other additional disabilities at the bottom of this page):
Attendant services may include assisting you with medication. Please describe which medications you take at present, including name, dosage and reason: (One line per drug)
The following questions are necessary for planning purpose and because of certain cost sharing agreements with the Federal Government. They in no way affect your priority for services.
Community Activity
Please check (√) which services you require and specify types of assistance and hours of services per week:
DECLARATION, CONSENT TO DISCLOSURE OF APPLICANT INFORMATION AND RELEASE FROM LIABILITY
I, the undersigned or the authorized representative, certify thatthis application is complete and correct, to the best of my knowledge.