First *

Middle *

Last *

Date

What is your payment type?

What is your Medicaid Number?

Insurance Carrier

Are you a Veteran or spouse of a Veteran? *

Yes

No

Do you have a spenddown? *

Yes

No

I don't know

If yes, spenddown amount: *

Do you meet your spenddown monthly? *

Yes

No

Telephone Number *

123-456-7890

Alternate Telephone *

123-456-7890

Physical Address

Street *

City *

State *

Zip *

County

Mailing Address

Street *

City *

State *

Zip *

County

Do you have a legal guardian?

Yes

No

If yes, guardian's name:

Guardian's telephone

123-456-7890

Please list up to 5 health conditions you are currently experiencing:

Single Line Text *

Single Line Text

Do you currently have home care services through another provder?

Yes

No

For the following topics please click the checkbox that best describes you:

MOBILITY

I do not need anyone to help me get around my home (never)

I only need help getting around my home every once in a while (once a week or less)

I need help getting around my home (more than once a week)

I need help getting around my home all of the time (every day)

Please further describe your mobility needs:

DIETARY

I have no special diet and do not need assistance preparing or eating meals.

I only need help with meals 50% of the time.

I need help with preparing meals 100% of the time.

I need help preparing meals 100% of the time and require tube feeding.

Please further describe your dietary needs:

Please further describe your restorative services:

MONITORING

I do not currently see a physician.

I see my physician(s) on a regular basis, but only for routine monitoring (weight, temperature, blood pressure, or other vital signs)

I see my physician(s) at least 1 time per month for a specific stable physical or mental condition(s).

I see my physician(s) at least 1 time per month for a specific unstable physical or mental condition(s).

I see my physician(s) at least weekly for an unstable physical or mental condition(s).

Please further describe your monitoring orders:

MEDICATIONS

I do not currently take any physician-ordered medications

I take medications ordered by my physician, but I can manage the medications on my own. My health condition(s) is stable.

I take medications ordered by my physician, but I require someone to set-up my medications for me or to remind me to take my medications. I have less than 9 medications on a daily basis.

I take medications ordered by my physician and I require someone supervise my medication intake. My health condition is considered unstable and/or I take more than 9 medications on a daily basis.

Please further describe your medication orders:

BEHAVIOR

I do not need behavioral assistance. I am oriented to my surroundings and my memory is intact.

I sometimes need supervision, guidance, or emotional support OR I have some memory lapses or occasional forgetfulness.

I need supervision all the time due to disorientation, mental or developmental disabilities, or improper behavior. OR you are frequently forgetful and has many memory lapses.

I require maximum behavioral assistance in the form of extensive supervision because of confusion, incompetency, hyperactivity, hostility, severe depression, or other behavioral characteristics.

Please further describe any behavior or memory issues:

TREATMENTS

I do not have any procedures or treatments ordered at this time.

I am ordered to use treatments such as elastic pressure stockings, whirlpool baths, TENS unit or other non- routine treatment.

I require daily treatments such as daily dressing changes, oxygen, oral suctioning, catheter/ostomy maintenance, care of skin disorders, dialysis, CPAP, nebulizer, or other daily treatments.

Please further describe your treatments:

PERSONAL CARE

I do not need assistance with any of my hygiene or personal care.

I need minimal assistance with hygiene or personal care.

I need moderate assistance with hygiene or personal care (close supervision)

I require someone else to perform all my hygiene or personal care needs.

Please further describe your personal care needs:

BOWEL AND BLADDER CONTINENCE

I have complete control over my bowel and bladder.

I have incontinence of my bowel and/or bladder once a week or less.

I have incontinence of my bowel and/or bladder 2-3 times per week.

I have incontinence of my bowel and/or bladder 4+ times per week.

Please further describe your continence needs:

REHABILITATION

I do not receive any rehabilitation services

I receive rehabilitation 1 time per week.

I receive rehabilitation 2-3 times per week.

I receive rehabilitation 4 or more times per week.

Rehabilitation services include at least one of the following: Occupational Therapy, Speech Therapy, Audiology, Physical Therapy, or Cardiac Rehabilitation.

Please further describe your rehabilitation orders:

Please review all information, then click on the submit button. Our staff will be in contact within the next 24 business hours. For questions regarding your submission, please contact our Program Director at 573-221-8282.

By clicking submit, you authorize NorthEast Independent Living Services to use the information you have provided to help determine eligibility for home care services. You further certify that all information submitted is true and correct to the best of your knowledge.

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CAPTCHA - What is the first letter of the last day of the week?

Apply For Home Care

Home Care Services Application

Physical Address

Mailing Address

Please list up to 5 health conditions you are currently experiencing:

For the following topics please click the checkbox that best describes you:

Disability in the Workplace

1st Quarter 2017

3rd Quarter 2016

2nd Quarter 2016

Apply For Home Care

Home Care Services Application

Physical Address

Mailing Address

Please list up to 5 health conditions you are currently experiencing:

For the following topics please click the checkbox that best describes you:

Disability in the Workplace

1st Quarter 2017

3rd Quarter 2016

2nd Quarter 2016

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