Client Self Onboarding Form
Intake Date
*
/
Month
/
Day
Year
Date
Client Name
*
First Name
Middle Initial
Last Name
Client Gender
Male
Female
Non-Binary
Date of Birth
*
-
Month
-
Day
Year
Date
Age
MA Number
Street Address
*
Apartment/Unit
City
*
State Abbreviation
*
Zip Code
*
County
Client Phone Number
*
Format: (000) 000-0000.
Client Email
example@example.com
Prefered Method of Contact
Mail
Email
Phone
Intake Person
Intake Person Direct Dial
*
Emergency Contact Name
Emergency Contact Phone Number
Format: (000) 000-0000.
Responsible Party Name
Responsible Party Phone Number
Format: (000) 000-0000.
Case Manager / Company
Phone Number
Format: (000) 000-0000.
Waiver type?
Doctor/Clinic Name
Doctor/Clinic Phone Number
*
Format: (000) 000-0000.
Hours Per Day
Date of Assessment
/
Month
/
Day
Year
Date
Are you on a healthplan (MSHO or MSC+)
Yes
No
Are you on Straight MA ?
Yes
No
Are you on the Restricted Program?
Yes
No
Diagnosis
Currently working with an agency?
*
Yes
No
If Yes, what Agency?
Any other Family members with Best Care?
PCA Name
Consumer
*
Responsible Party
Policy Acknowledments
*
I have received and reviewed the Best Care policy manual
Communication Authorization
*
I authorize Best Care to send unsecure communication in the event I am unalbe to open a secure communication.
I do not authorize Best Care to send unsecure communication in the event I am unalbe to open a secure communication.
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