Application

Broker/IOA Name:
Broker/IOA Email:
Broker/IOA NPI Number:
FMO Name:
Broker/IOA Phone:
Broker/IOA Agency:
Notes:


Email:
Birthdate:
Gender:


Best Time to Call:
Social Security#:
Primary Language:
Center:
Address1:
Address2:
City:
State:
Zip:
County:

Are you a US Citizen?:
Receive Mail at This Address?:
How long at this address?:
If with family/caregiver, who? (Name):
Anyone told you that your area is unsafe:
Plan to move to Memory Care or SNF?:
Private Home/Apt:
Alone:
Assisted Living:
With family/caregiver:
Residential Care Facility (RCFE):
With Roommates:
Board and Care:
Skilled Nursing Facility (SNF):
Homeless:
Other Living Situation:
Healthcare Decision Maker Name:
Healthcare Decision Maker Phone:
Healthcare Decision Maker Relationship:
Healthcare POA Name:
Healthcare POA Phone:
Healthcare POA Relationship:
Finance POA Name:
Finance POA Phone:
Finance POA Relationship:
Advanced Directive in Case of Emergency:
Any plan to leave the area in next 30-60:
If yes,provide date:
Diabetes:
Dialysis:
Heart problems:
High Blood Pressure:
COPD:
Oxygen use:
Pain Issues:
Memory Problems:
Mental Health conditions:
Anxiety:
Depression:
Bipolar Disorder:
PTSD:
Schizophrenia:
Schizoaffective Disorder:
Personality Disorder:
Falls in Last Year:
Falls in Last Month:
Worsening?:
Have You Seen an Increase in Falling?:
Do You Walk Unassisted?:
Are you using a wheelchair?:
Medications taken on regular basis:
Do you use illegal drugs:
What type of illegal drugs:
Do you receive any help at home?:
Hours per week:
IHSS/State-funded:
Family member is state-paid caregiver:
Private Agency:
Private Agency Name:
Bathing:
Dressing:
Eating/ Meals:
Toileting:
Ambulation:
Transferring:
Medication Management:
Shopping:
Other:
Other Type Name:
Willing to change home care to PACE:
Do you use any assistive devices?:
Any firearms in the house:
Location of firearms in house:
Guns kept locked:
Gun and ammunition kept separately:
Pets in the home:
Pets in the home, what is your plan in a:
Willing to receive care from new PCP:
Current PCP Name:
Current PCP Contact Information:
How Long with Current PCP?:
Current Specialty Provider 1 Name:
Current Specialty Provider 1 Phone:
Specialty Provider 1 Contact Information:
Why are you seeing a specialty provider?:
Current Specialty Provider 2 Name:
Current Specialty Provider 2 Phone:
Specialty Provider 2 Contact Information:
Why are you seeing Specialty Provider 2?:
Do you see a psychiatrist regularly:
See a counselor/therapist regularly?:
Psychiatrist/Counselor/Therapist Name:
Psychiatrist/Counselor/Therapist Phone:
Name of mental health care provider:
Phone of mental health care provider:
Address of mental health care provider:
Reason for seeing mental health provider:
Medi-Cal eligibility active:
Medi-cal #:
How is your name listed on your Card?:
Details of pending issues w/ Medi-Cal:
Need help with Medi-Cal Application?:
If yes, were all documents collected?:
In renewal process for Medi-Cal?:
Share of Cost(SOC) for Medi-Cal:
Willing to pay?:
Amount of SOC:
Is your Medi-Cal in another county?:
Medicare Eligible:
Medicare#:
Name of Other Health Insurance Provider: