SeniorCare Homecare Intake Form

SeniorCare Homecare Intake Form

Updated: 4/1/2022
When anticipating discharge from a hospital/rehabilitation facility,
PLEASE DO NOT SEND PRIOR TO THE DISCHARGE DATE.

For those residing in a community/home setting, complete and submit this form, and an Information & Referral specialists will reach out to you.

FORM COMPLETED BY
Name of person completing this form*

First NameLast Name
Organization & TItle
Address*

Street Address

Street Address Line 2 (if needed)

CityState

Zip Code
Email*
example@example.com
Phone Number*
What is the relationship between the person completing this form and the consumer?*

HEALTH & INSURANCE INFORMATION
Medicare*

YesNo
MassHealth*

YesNo
If answered "Yes" to MassHealth, please enter MassHealth Number*
If entered "No" to MassHealth, enter N/A
PCP Name*

First NameLast Name
PCP Phone*
Please enter a valid phone number.
Major Medical Conditions

RECENT HOSPITAL ADMISSION
Hospital Admission in Last 90 Days?*

YesNoUnknown
If answered "Yes" to hospital admission, please indicate which hospital and dates of stay-- Both ADMIT and DISCHARGE dates are very important*
If answered "No" to hospital admission, enter N/A
If answered "Yes" to hospital admission, please indicate reason for admission*
If answered "No" to hospital admission, enter N/A
If answer "Yes" to hospital admission, did the consumer stay at a rehab facility following the hospital stay?*

YesNoUnknown
If answered "Yes" to rehab admission, please indicate which rehab facility and dates of stay*
If answered "No" to rehab, enter N/A
Rehab discharge date*

MonthDayYear
Date
Was VNA involved?*

YesNoUnknown
If answered "Yes" to VNA involvement, please indicate which VNA*
If answered "No" to VNA, enter N/A

CONSUMER KNOWLEDGE OF REFERRAL
Is the Consumer aware of this referral?*

YesNoUnknown
Contact Consumer to complete referral?*

YesNo
If Consumer is not aware of this referral, why?*
If consumer is not to be contacted, please explain why
If Consumer is not to be contacted to complete referral, who should be contacted?*

First NameLast Name
Phone number for contact to complete referral*
Please enter a valid phone number.
Relationship to the Consumer of contact

Please do not send this form prior to the discharge date