Family Caregiver Contact Form - Home Care Network, Inc.

Your Contact Information & Caregiver Intent

Your First Name

Your Last Name

Your Phone

Your Email

Best way to Contact you:

Zip Code of Your Residence

What is your primary goal today?

Become a paid caregiver for my child/spouse/family member/loved one or acquaintance.
Sign up/Hire someone else I know to be a paid caregiver for my child/spouse/family member/loved one or acquaintance.
Find a professional caregiver or nurse from your agency to provide care to my loved one.
A mix of both (I want to get paid to care for them, but we also need additional caregivers).
Learn more about your paid family caregiver program.
Other / Additional Goals

Select ALL that apply (one or more).

Care Configuration & Arrangements

My Relationship to the patient is:

Select one.

The patient I'm inquiring about care / caring for is a/an:

Who will be providing care for the patient?

Just myself as a paid family caregiver.
Myself AND another family member / known person.
Myself AND a professional agency caregiver or nurse.
Myself AND another family member / known person AND a professional agency caregiver or nurse.
ONLY another family member / known person (I do not wish to be hired). (I do not wish to be hired).
ONLY professional agency caregivers / nurses (I do not wish to be hired).
Other

Select one.

Which of the following best describes the current living arrangement of the care recipient (patient)?

They live with me in my home.
We live together in our home.
I live with them in their home.
They live on their own (alone).
They live on their own (with a spouse, family member, or roommate).
They live independently in a group setting (independent living facility, group home, etc.).
They live in a professional care facility (assisted living, nursing home, etc.).
Other (please specify).

Select one.

Patient Eligibility & Assessment Information

All Patient Details below are / will be required to perform an eligibility check. While not required at this time, providing as much of this information now will expedite the process, allow us to run a free eligibility check prior to contacting you, and allows us to provide the best, most personalized options for you and the patient.

Patient Name

First

Last

Patient City, State & Zip Code

Patient's County of Legal Residence

This is required.

Patient's Parent / Legal Guardian Name:

First

Last

Only required if Patient is a minor that is not your child)

Patient Phone (if patient is adult) or Patient's Parent/Legal Guardian Phone (if patient is a minor that is not your child):

Patient Date of Birth

Month / Date / Year (Ex: 12/25/2009). This is / will be required to perform an eligibility check.

Patient's Insurance Provider / Coverage:

Select all that apply.

Patient's Medicaid ID / Member ID

This is / will be required to perform an eligibility check.

Does the patient currently receive (or has recently received) any in-home care, home health, or waiver services?

Open-Ended Questions & Next Steps

What questions or concerns do you have for our team?

Consent to Respond & Communicate

YES, I consent to receive HCN’s response and company communications via Email, Phone, or Fax. By selecting “Submit”, you confirm that you have read and agree to HCN’s Terms of Use and Privacy Notice.

Required.

YES, I consent to receive HCN’s response and company communications via SMS / Text. Based on your phone plan, message and data rates may apply, and I may withdraw consent at any time in the future.

Required if Cell Phone number provided as contact.

Consent to Verify Patient Benefits

YES, I authorize Home Care Network, Inc. to verify the patient’s insurance and Medicaid eligibility to determine program options, and have the legal ability to grant this consent for this patient.
NO, I do NOT authorize Home Care Network, Inc. to verify the patient’s insurance and Medicaid eligibility to determine program options at this time.
NO, authorization for Home Care Network, Inc. to verify the patient’s insurance and Medicaid eligibility to determine program options must be obtained from the Patient (if an adult) or the Patient’s Parent / Legal Guardian (if a minor that is not my child) – of which I am neither. However the Patient / Patient’s Parent/Guardian is aware of my interest and welcomes Home Care Network, Inc. to contact them.

Select one.

Custom Captcha

=