P P Home Services, LLC
Medicaid Waiver Referral Form
Client Information
Last Name:
First Name:
Middle Initial
Today's Date
City, State
Living Arrangement: Independent w/Family Member w/Roommate
Legal Status: Minor Emancipated Adult Has Legal Guardian
If Client has a Legal Guardian-Please provide name and phone number below
Male Female
Name Phone
SS # (Last 4 digits)
Current Waiver Information: Is there an existing NOA? Yes No
Medicaid ID #
NOA Annual Date __________________ NOA Approval Date
Services Needed: RHS RATT FCAR ATTC Other Medicare ID #`
Staffing Needs:
Names of Potential Staff:
Has Current Staff
Type of Waiver
Needs Staff
How did you hear about us?
Primary Contact Information
Primary Contact First and Last Name
Primary Contact Phone Number
Primary Contact Address
Alternate Phone Number
Primary Contact City, State, Zip Code
Email Address
Relationship to Client (ie: Father, Brother, Cousin, etc.)
Case Manager Information
Case Manager First & Last Name
Case Manager Phone Number
Case Manager Agency and Address
Case Manager Alternate Phone Number
Case Manager Email Address
Office Use Only
Date Referral Received:
Initial Contact with Client
Date of Initial Meeting with Client
Results of Meeting
Anticipated Start Date with P & P Home Services, LLC