Intake Form - Senior Life Planning

Client First, MI, Last Name *

First

Middle

Last

Client Social Security Number

Client Race

Client Race - Other (copy)

Client Birthdate *

U.S. Citizen? *

Disabled? *

Yes
No
Unsure

Blind? *

Veteran? *

Please provide service dates:

Were any of those dates in service in active duty?

Surviving spouse of veteran?

Spouse: First, MI, Last Name:

First

Middle

Last

Spouse: Social Security Number (not required if spouse does not want Medicaid)

Spouse: Birthdate

Spouse: Race

Spouse Race - Other

Date of Marriage

Address of Home Residence *

Address Line 1

City

State

Zip Code

Is your mailing address different than your residence?

Mailing Address

Email *

Residence of Individual

Residence - Other

If Individual is in a Care Facility

Care Facility Name

Care Facility Address

Address Line 1

City

State

Zip Code

Care Facility Phone Number

On what date did they enter this facility on a continuous basis?

How many days have then been in this facility?

Family Representative Information

Family Representative Name (First, MI, Last Name) and Relationship

Address

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone

Cell Phone Number

Work Phone Number

Email *

If you are caring for an elderly family member who may need Medicaid coverage in a care facility in the future, do you currently have a Caregiver Agreement in place?

Yes
No
Other

If other:

Medical Data

Diagnosis

Prognosis

Course of Treatment

Has an FL-2 form been completed? *

Yes
No
Other

If other:

Do you or your spouse need help paying for services received in the last 3 months?

If yes, please send scanned copies to info@parkereldercare.com or bring them to your consultation.

County of residence where the medicaid applicant will be applying for benefits

If you are found eligible for full Medicaid benefits, you have the right to assistance with medical transportation. Do you or your spouse need help with transportation to medical services?

Health Insurance

Do you have health insurance, Medicare, or Medicare HMO? *

If yes, which ones?

Medicare claim number:

Insurance Company

Policy Number

Policy Holder's Name *

First

Middle

Last

Policy Holder's Date of Birth

Policy Holder's Relationship to Client

Are you enrolled in a Prescription Drug Plan?

If yes, which one:

Have you or your spouse had an accident in the past 12 months?

Yes
No
Other

If other:

Medicaid Planning Intake Form

If Individual is in a Care Facility

Family Representative Information

Medical Data

If yes, please send scanned copies to info@parkereldercare.com or bring them to your consultation.

Health Insurance