New Client Intake Form - Home Care Network, Inc.

HCN New Client Intake Form & Eligibility Check Authorization

General Form Submission Information

A. Who is completing this form?

I am the prospective client/patient seeking services for myself.
I am completing this form on behalf of someone else.

Form Completer Information

Full Name

First

Last

Relationship to Client

Phone

Email

Are you involved in making Care Decisions for this Client?

Yes or No | Include any additional details if desired.

Client Information

Client Full Name

First

Last

Date of Birth

MM/DD/YYYY

Home Address

Address Line 1

Address Line 2

City

State

Zip Code

County of Residence

Best Contact Phone Number for Client

Client's Primary Care Physician Name (or Dr. who will be signing off / approve services)

Client's Case Manager Name (if applicable)

Case Manager Phone Number

Case Manager Email

Client Insurance Information

Medicaid ID # or Social Security Number

At least one is REQUIRED: We cannot run eligibility on a client without at least one of these #s.

List all relevant Insurance Provider(s) + Member # / Policy ID(s) for each (if known)

Managed Care Plan Name (if applicable)

Medicare ID # (if applicable)

Optional but Beneficial Care Needs Information

Completer Network? Phone

Primary diagnosis or health concerns

Recent hospitalizations or rehabilitation stays

Current services being received (if any / known)

Immediate concerns or support needs

16. Which of the following Caregiver Arrangements are you interested in exploring with Home Care Network? (Select all that apply)

Receiving care from professional caregivers or nurses employed by our agency (HCN)
Becoming a paid caregiver for my loved one / Hiring a loved one to be my paid caregiver
Having another family member, friend, or known individual become a paid caregiver
Hiring a specific caregiver I already know
Combining family caregiver services with agency caregivers
Learning more about your Paid Family Caregiver Program
Unsure — I would like recommendations based on my situation
Other: (please specify below)

Other (Caregiver arrangement)

NEXT STEPS:

Complete all 3 Consent Questions and click the “SUBMIT” button below to engage HCN in a free, no-pressure Eligibility Check for you / this patient.
HCN will run an eligibility check to determine approved services, payor sources, and care requirements for you / the client. This takes between 1-5 business days.
Our team will reach out to schedule a consultation call, discuss care options and recommendations, and determine next steps with you.

QUESTIONS?

Call us: 1-800-600-3974 (8am–5pm EST)

Email us: hcnintake@hcnmidwest.net

Consent & Submit

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.

Optional.

Consent to Verify Patient Benefits (Select One)

YES, I authorize Home Care Network, Inc. to verify the patient’s insurance and Medicaid eligibility to determine program options, and have permission / 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) – of which I am neither nor do I have permission to do so. However the Patient / Patient’s Parent/Guardian is aware of my interest and welcomes Home Care Network, Inc. to contact them.