Info Cover Sheet – COMMUNITY CONNECT HOME CARE LLC

Service Recipient Information Cover Sheet / Admission Form

Person Information

First name *

Last name *

Admission Date

Service Initiation Date

Date of Birth

Gender

Social security number

Address

Phone number

Cell number

Waiver Type

Service Type

Insurance Information

Primary insurance number

Medical Assistance number

Medicare number

Other insurance information

Legal status

Responsible for self Under guardianship Under commitment

Legal representative contact information

Legal representative first name

Legal representative last name

Legal representative address

Legal representative office number

Legal representative cell number

Primary emergency contact information

Emergency contact first name

Emergency contact last name

Emergency contact address

Emergency contact office number

Emergency contact cell number

Case Manager contact information

Case Manager first name

Case Manager last name

Case Manager address

Case Manager office number

Case Manager cell number

Health information

Medical history

Special dietary needs

Allergies

Health care provider contacts information

Primary physician name

Clinic Name

Address

Phone number

Fax number

Health care provider name (2)

Clinic Name (2)

Address (2)

Phone number (2)

Fax number (2)

Health care provider name (3)

Clinic Name (3)

Address (3)

Phone number (3)

Fax number (3)

Medical appointments

Program assists with setting up medical appointments

Yes No

Other Service Providers

Add as many providers as needed.

Community

Service Recipient Information Cover Sheet / Admission Form

Person Information

Insurance Information

Legal status

Legal representative contact information

Primary emergency contact information

Case Manager contact information

Health information

Health care provider contacts information

Medical appointments

Other Service Providers