Internet Inquiry Information

Please provide a brief description about the reason you are contacting us:

Contact Person Information:

Name of Person contacting us: Relation to Client:

Best times to contact you: Best way to contact you:

Home Phone: Cell Phone: Email Address:

Address: City: State: Zip:

How were you referred to us:

	Dr. Office		Friend		Hospice		Elder Law Attorney		Hospital discharge planner		Nursing Home discharge planner
	Visiting Nurses of Albany		Visiting Nurses of Schenectady		Other Home Health Care Agency (Name: )		Yellow Pages		Attentive Website
	Other Internet Site (Name: )		Other

Emergency Contact

Are you the person to contact in a medical or otherwise emergency? Yes No

If No, complete the following emergency contact person information:

Last Name: First Name: Relation:

Home Phone: Cell Phone: Email Address:

Address: City: State: Zip:

Special Instructions:

Client Information

Type of Caregiver requested:

Unsure what is needed Registered Nurse Practical Nurse Home Health Aide Personal Care Aide Companion sitter

Note:

Times of Service requested:

Unsure what is needed Live-in Visits/Week Hours/day Days/Week

Please indicate desired schedule below:

	SAT	SUN	MON	TUE	WED	THR	FRI
Time In
Time Out

Client Location Albany Nassau & Queens Suffolk

Client Last Name First Middle

Female Male      Date of Birth Weight SS#

Home Phone # Cell Phone # Email Address

Directions to Client's Location

Diagnosis

Medications required No Yes Self Administered No Yes Oxygen required No Yes

Does the client have an involved family support system No Yes

Attending Physician

Last Name: First Name: Phone #:

Address: City: State: Zip:

Directions to Physician's Office Location:

Hospital Used: Pharmacy Used: Pharmacy Telephone:

Client Needs Assistance With

Aide Level Services

Oral Hygiene	Partial Assistance Total Assistance
Skin Care	Partial Assistance Total Assistance
Bathing/Shampoo	Partial Assistance Total Assistance
Walking	Partial Assistance Total Assistance
Transfers	Partial Assistance Total Assistance
Exercise	Partial Assistance Total Assistance
Toileting	Partial Assistance Total Assistance
Meal Prep	Partial Assistance Total Assistance
Reminder Meds	Partial Assistance Total Assistance
Shopping/Errands	Partial Assistance Total Assistance
Light Housekeeping	Partial Assistance Total Assistance
Laundry	Partial Assistance Total Assistance
Lives Alone	No Yes    Lives With?
Smokes	No Yes
Pets?	No Yes    If Yes, type

Skilled Services
(Check all that Apply) Client needs assistance with

IV Therapy
Medication Assistance
Total Parenteral Nutrition (TPN)
Tube Feeding
Ostomy Care
Catheter Care
Tracheostomy Care
Ventilator Care
Wound/Dressing Care
Injections
Teaching
Case Management

Billing Information

Name of Responsible Party Phone #

Address: City: State: Zip:

Payment Source

Private Managed Care Medicaid EISEP    Fidelis CDPHP Senior Whole Health Long Term Care Insurance Workers Compensation NYSARC Trust Nursing Home Transition and Diversion Program (NHTD)

Name of Insurance Company Member Id

Insurance Contact Person Phone