FAX COVER SHEET - Senior Connection Center, Inc.
FAX REFERRAL FORM - COVER SHEET
TO: Please fax this information to the fax line at 1(888) 401-4606. This form can also be scanned and sent to ir@.
FROM:
SUBJECT:
DATE:
# OF PAGES: 2 (including cover sheet)
Message: The person requires assistance with the following:
Information and Referral – Information and/or referral for community services and programs available to developmentally disabled adults, seniors and/or their caregivers.
Intake and Screening - Telephone screening for home and community-based services, including services in the home or in an assisted living facility. This may include instances when the person already received a telephone screening and there was a recent significant change, or the person needs assistance with accessing additional home and community-based services.
SHINE - Medicare Counseling Assistance; this may include the Low Income Subsidy (Extra Help) and/or MSP Medicare Savings Programs.
|General Referral Information: *The information provided below helps us to respond appropriately to your request. |
|Name of the person or company making the referral: |
| |
|Date of the referral: |
| |
|Is the consumer aware that this referral was made on their behalf? |
|Yes No |
|Specific Referral Information: |
|Name of consumer: |
|Social Security #: |DOB: |
| | |
|Address: |City & State: |
| | |
|Zip Code: |County: |
| | |
|Phone Number, Email Address (optional): |Alternate Phone Number, if applicable: |
|Person to be contacted: |Best time to call: |Language Preferred: |
|Please describe the situation in detail, including the specific type of assistance needed. |
|Does the consumer currently have a caregiver who provides regular and consistent care? |
|Yes No |
|Is the client currently receiving any type of assistance or |If yes, what services? |
|services? | |
|Yes No | |
|Have any other referrals for assistance already been made? |If yes, what referrals for assistance were already made? |
|Yes No | |
|If there is any other pertinent information you would like to provide, please use the space below. |
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