P P Home Services, LLC
Medicaid Waiver Referral Form
Client Information
Last Name
First Name
Middle Initial
Today's Date
Zip Code
Address
City, State
County
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Living Arrangement: ____ Independent ____ w/Family Member ____ w/Roommate
DOB
Diagnosis:
Legal Status: ____Minor ____ Emancipated Adult ____ Has Legal Guardian
Gender:
If Client has a Legal Guardian-Please provide name and phone number below
Male____ Female____
Name ________________________________________ Phone ____________________
SS # (Last 4 digits)
Address ___________________________________________________________________
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
Concerns
Anticipated Start Date with P & P Home Services, LLC
Effective Date 7-1-11
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