Consumer Application - APD Services, Homemaker, …

[Pages:25]5317 East 20th Avenue Tampa, FL 33619

Office: (813) 374-0984 Fax: 1 (888) 808-9686 Email: info@ Website:

Consumer Application Packet

DATE 1. ____________ 2. ____________ 3. ____________

____________ 4. ____________ 5. ____________

____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ 6. ____________ 7. ____________ ____________ ____________ 8. ___________

Helping Heart, LLC

CONSUMER FILE CHECKLIST

FORMS/INFORMATION Consumer Information Sheet / Demographic Information Health / Behavioral Assessment Support Plan or Outcome Page Service Authorization and Other Billing Documents Implementation Plan Consent to Release of Confidential Information Form Emergency Notification Authorization for Routine Medical/Dental Authorization for Photograph Authorization for Transportation Religious Information Abuse Hotline Information Receipt Bill of Rights Receipt HIPAA Policy Receipt Grievance Policy Receipt Incident Reporting Policy Schedule for Individual Service Annual Summary Monthly Summary Service Logs Additional documentation to proof of Legal status:

? Guardianship/Power of Attorney ETC.

Do not duplicate without the permission of Helping Heart, LLC

Helping Heart, LLC

Do not duplicate without the permission of Helping Heart, LLC

Helping Heart, LLC

Consumer Information Sheet

DEMOGRAPHIC

Date: ___________________________ Primary Disability: ___________________________

Secondary: ___________________________ County: ___________________________ DOB: ___________________________ Gender: _________ M _________ F

Legal Status: ___________________________

Primary Language: ___________________________ Nicknames: ___________________________

INSURANCE / RESOURCES

Consumer Name: _____________________________ SS #: _____________________________

Address: _____________________________ _____________________________

Phone (Day): _____________________________ Phone (Evening): _____________________________ Guardian Name: _____________________________ Power of Attorney :___________________________ Interpreter Name: _____________________________

Phone: _____________________________

Medicaid #: ___________________________

Medicare #: _____________________________

Other Insurance: ___________________________

Policy #: _____________________________

3rd Party Benefits: ________ SSI ________ SSA / DI

Amount: _____________________________

Income Source: ___________________________

Amount: _____________________________

Employer: ___________________________

Address: _____________________________

Supervisor: ___________________________

Phone: _____________________________

Available Transportation: _________ None

________ Waiver

_______Bus _______Family

PEOPLE TO CONTACT

Relationship

Name

Address

Phone

Guardian: _______________________________ _________________________________ _____________

Mother: _______________________________ _________________________________ _____________

Father: _______________________________ _________________________________ _____________

Other: _______________________________ _________________________________ _____________

Friends: _______________________________ _________________________________ _____________

_______________________________ _________________________________ _____________

Physician: _______________________________ _________________________________ _____________

Do not duplicate without the permission of Helping Heart, LLC

Helping Heart, LLC

Hospital: _______________________________ _________________________________ _____________ Dentist: _______________________________ _________________________________ _____________

_______________________________ _________________________________ _____________ _______________________________ _________________________________ _____________ WSC: _______________________________ _________________________________ _____________

Do not duplicate without the permission of Helping Heart, LLC

Helping Heart, LLC

SPECIALIZED NEEDS AND CHARACTERISTICS

Medical:

Diagnosis: ___________________________________________________________

___________________________________________________________

___________________________________________________________

___________________________________________________________

Medications: ___________________________________________________________

___________________________________________________________

Allergies:

___________________________________________________________

___________________________________________________________

___________________________________________________________

Family History: ___________________________________________________________

___________________________________________________________

Psychiatric: Diagnosis: ___________________________________________________________

___________________________________________________________

___________________________________________________________

Medications: ___________________________________________________________

___________________________________________________________

Family History: ___________________________________________________________

___________________________________________________________

Behavioral: Issues:

___________________________________________________________

___________________________________________________________

Interventions: ___________________________________________________________

___________________________________________________________

Do not duplicate without the permission of Helping Heart, LLC

Helping Heart, LLC

Consent to Release Confidential Information

_____________________________________ Consumer Name

______________________________ SS#

The Helping Heart, LLC has my consent to release to or obtain from:

NAME:

_______________________________________________________________

PURPOSE: _______________________________________________________________

ADDRESS: _______________________________________________________________

_______________________________________________________________

PHONE:

_______________________________________________________________

The following information contained in my file and/or record

__________ Daily documentation forms

_________ Financial Information

__________ Implementation plans

_________ Monthly summaries

__________ Annual summaries

_________ Other: ______________

Your signature below authorizes Helping Heart, LLC, to release or obtain only those items checked. Do not sign unless all items on form are complete.

___________________________________________ Consumer

_______________________ Date

___________________________________________ Parent/Guardian/Caregiver

_______________________ Date

Do not duplicate without the permission of Helping Heart, LLC

Helping Heart, LLC

Emergency Notification

_____________________________________ Consumer Name

______________________________ SS#

In case of sickness or death, please indicate the person(s) to be notified:

NAME:

_______________________________________________________________

RELATIONSHIP: _______________________________________________________________

PURPOSE: _______________________________________________________________

ADDRESS: _______________________________________________________________

_______________________________________________________________

PHONE:

_______________________________________________________________

In the event the above cannot be contacted, please indicate an alternate:

NAME:

_______________________________________________________________

PHONE:

_______________________________________________________________

In the event of death, please specify any preferences for funeral arrangements:

NAME:

_______________________________________________________________

ADDRESS: _______________________________________________________________

_______________________________________________________________

PHONE:

_______________________________________________________________

COMMENTS: _______________________________________________________________

___________________________________________ Consumer

___________________________________________

_______________________ Date

_______________________

Do not duplicate without the permission of Helping Heart, LLC

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