Alabama Department of Senior Services Elderly and Disabled ...
| |
|Alabama Tombigbee Regional Commission Area Agency on Aging |
|Intake/Referral |
CLIENT INFORMATION
|Source of Income |
| |
|SS Full Medicaid SSI Deeming QMB/SLMB/QI Pension Medicare Part A B C D # in household____ |
| |
|Income/m _____ Amount in Bank ______ Owns Property____ Life/Burial_____ SNAP ____ POA _____ Will ________ |
|Does client have any of the following? |
| |
|AIDS/HIV Arthritis CHF Diabetes HTN Paralysis Seizures |
|Alcohol/Drug Asthma COPD Falls Mental Illness Parkinson’s |
|Alzheimer’s Blindness CVA Heart Disease Mental Retardation Renal Failure |
|Amputation Cancer Dementia High Cholesterol Obesity > Weight ________Height_______ |
| |
|Recent Hospitalization (date)_____________________ NH (discharge date)_____________________ |
| |
|Cane Walker Wheelchair Oxygen Hoyer Lift Other __________________________ |
|****SERVICES NEEDED**** |
| |
|_______________________________________________________________________________________________________ |
| |
|Current Services in the Home: Home Health Hospice DHR Other________________________________ |
CAREGIVER INFORMATION
-----------------------
Return by mail to:
Tiffany Walters
107 Broad St
Camden AL 36726
Return by fax to:
334-682-4045
Zip
Social Security #
City
Telephone #
Date of Referral
Address
Medicaid #
Name
Doctor
Date of Birth
County
Last Visit
Telephone
DOB
Telephone #
Relationship
Comments:
State
County
Zip Code
City
Address
Name
Client Referred To: AL Cares SenioRx In-Home MedWaiver Other ______________________________
Name of Intake Person
Relationship
Referral Source
Telephone #
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