Sincere Home Care Service's 248-918-4444
Client Application
CLIENTS FIRST AND LAST NAME
*
CLIENTS PHONE
*
Address # Street, City, State, Zip Code)
*
DATE OF BIRTH
*
SOCIAL SECURITY
Medicaid ID Number
Do you have Medicare?
Yes
No
Unsure
Do You have Medicaid?
Yes
No
Unsure
Who would you like to be your caregiver?
A friend or relative (Sincere Home Care will pay them $16.00/hr)
I would like to have someone sent from the agency.
ARE YOU MARRIED
YES
NO
Upload Social Security
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of
Upload license or state ID
Upload a File
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of
Check Box
HOME HELP
If you have Caregiver in mind Name and Number
Email
example@example.com
Your Dr.'s Name and Number
*
I acknowledge that I have read the Preview Pdf and fully understand and agree to the terms and conditions .
Signature
*
Date
-
Month
-
Day
Year
Date
Steps
Please Select
1. No Signatures
2. Signed
3. Emailed to Macomb
3. Fax Sent to County
4. County Received -Not Yet assigned SW
5. SW needs 54a email
6. Awaiting Interview
7. $Start Caregiver - Services Approved$
8. $$$$Services Active$$$$
Close Case / Cold Lead
New Case / Approved for Hours
1. Visiting Dr
Does Not Want Visiting Dr
Dr Signed / Call Client
Waiting Sw Name
Not Using us
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NOTES
Should be Empty: