Client Application Form | CarePlus Health Solutions

Step 1 of 7

Client Information

Office Use Only

This section will be completed by CarePlus staff after submission.

Application / Referral Date Initial Contact Date Referral Source Requested Start Date Intake Coordinator Client ID

Client Information

Legal Name (Last, First, Middle) * Preferred Name Date of Birth * Age Sex Preferred Pronouns Home Address * City * State * ZIP Code * Primary Phone * Alternate Phone Email Address * Preferred Language *

Interpreter Needed? * Yes No

Marital Status

Responsible Party / Primary Contact

Name * Relationship to Client * Primary Phone * Alternate Phone Email Address Address (if different from client)

Legal authority (if applicable)

POA Guardian Healthcare Agent None

Documentation on file? Yes No

Emergency Contacts

Emergency Contact #1 - Name * Relationship * Phone * Emergency Contact #2 - Name Relationship Phone

Step 2 of 7

Health & Functional Information

For intake, assessment, and service-planning purposes

Primary Medical Information

Primary Care Physician Phone Fax Preferred Hospital Pharmacy Pharmacy Phone

Primary Diagnosis / Health Conditions Allergies (medication, food, environmental) Current Medications (attach list if available) Medication list attachment (optional)PDF, JPG, PNG, DOC, or DOCX. Maximum 2 MB.

Cognition, Communication & Special Needs

Memory impairment / confusion Hearing impairment Vision impairment Speech / communication difficulty Behavioral health concerns Developmental / intellectual disability Swallowing difficulty Special diet / nutrition needs

Additional clinical, functional, or communication information

Step 3 of 7

Safety & Emergency Information

Home safety screening and emergency preparedness

Home Environment

Client lives alone Stairs in home Elevator available Wheelchair-accessible entrance Working smoke detectors Working carbon monoxide detector Other household members present Utilities currently operational

Access instructions / gate code / parking / relevant home information

Emergency Preparedness

Emergency Evacuation Destination / Shelter Person Assisting in Emergency Emergency Contact Phone Backup Caregiver / Support Person Phone

Emergency plan notes (power outage, severe weather, oxygen/equipment needs, evacuation assistance)

Advance Directives & Decision-Making

Advance Directive exists Healthcare POA exists DNR / POLST or similar order None known

Healthcare Agent / Decision Maker Phone

Location of advance directive / special instructions

Step 4 of 7

Requested Services & Schedule

Initial request - final services are confirmed in the service agreement and service plan

Requested Schedule

Day	Start Time	End Time	Hours	Notes
Mon
Tue
Wed
Thu
Fri
Sat
Sun

Estimated Hours per Week Preferred Start Date * Expected Duration of Services

Client Preferences

Caregiver preferences (when relevant to care, privacy, safety, or cultural needs)

No preference Female caregiver Male caregiver

Language / Communication Preference Cultural / Religious Considerations

Daily routines, interests, and preferences important to the client

Step 5 of 7

Payment, Billing & Authorizations

Information used for intake, billing, benefits, and care coordination

Payment Information *

Private Pay Long-Term Care Insurance Medicaid / Waiver Other

Responsible Party for Payment Relationship to Client Billing Address City State ZIP Code Phone Email

Insurance / Benefit Information (If Applicable)

Insurance / Program Name Member / Policy ID Group Number Claims / Authorization Phone Case Manager Case Manager Phone Authorization Number Authorized Hours / Units

Communication & Information-Sharing Preferences

I authorize CarePlus Health Solutions, as needed for care coordination and payment, to communicate with:

My physician / healthcare providers Responsible party listed in this application Emergency contacts Insurance / benefit program Pharmacy Other authorized person(s) listed below

Other Authorized Person(s) Relationship / Purpose

Documents Provided / Reviewed at Intake

Government-issued ID Insurance / benefit cards Medication list Advance directive / POA Hospital discharge instructions Physician orders / relevant records Client Rights & Responsibilities Privacy / confidentiality notice

Other documents / notes Supporting documents (optional)Up to 3 files total across this application. PDF, JPG, PNG, DOC, or DOCX. Maximum 2 MB each and 3 MB total.

Step 6 of 7

Acknowledgments & Signatures

Applicant attestation and CarePlus intake review

Applicant / Responsible Party Acknowledgments I certify that the information provided in this application is true and complete to the best of my knowledge. * I understand that submitting this application does not guarantee acceptance, staffing availability, or a specific start date. * I understand that the services, schedule, charges, billing terms, and cancellation terms will be confirmed in a separate written service agreement. * I understand that an individualized service plan will be developed and updated as required based on the services provided and the client's needs. * I authorize CarePlus Health Solutions to use the information in this application for intake, care coordination, service planning, billing, quality activities, and legally required operations. * I understand that the client may participate in service planning, accept or refuse services, ask questions, and raise complaints without retaliation. * I understand that emergency medical needs should be directed to 911 or the appropriate emergency service; CarePlus Health Solutions is not an emergency response service. *

Client / Responsible Party Signature

Printed Name * Relationship to Client * Signature *Type your full legal name. This serves as your electronic signature. Date *

CarePlus Intake Review

This section will be completed by CarePlus staff after submission.

Reviewed By Title / Credentials Signature Date

Disposition

Proceed to assessment / service agreement Additional information needed Unable to accept referral at this time Referred to another provider / resource

Intake notes / follow-up actions

Recordkeeping note: This application is an intake tool. Georgia private home care rules separately require a written service agreement, a current service plan, and other client-record documentation. Review this form periodically for changes in applicable law, payer rules, and agency policy.

Step 7 of 7

Review & Submit

Confirm your information before sending the application.

Client Application for Home Care Services

Online Application

Client Information

Health & Functional Information

Safety & Emergency Information

Requested Services & Schedule

Payment, Billing & Authorizations

Acknowledgments & Signatures

Review & Submit

Application Submitted