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Elder Care Alliance
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Caregivers
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Referrals
Caregiver Solutions Referral form
BEI Referral form
FAQs
Referral / Information Request form
Are you seeking information or making a referral for yourself or someone else?
Myself
Family Member
Friend
Patient or Client
Someone Else
Your Information
First Name
Last Name
Email
Phone Number
Company
Address
Apt/Suite
City
State
Zip
Does the consumer Know that a referral is being made on their behalf
Yes
No
Does the consumer live alone
Yes
No
If no, Who do they live with
Client / Patient Information
First Name
Last Name
Birthday
Gender
Prefer not to say
Female
Male
Transgender Female
Transgender Male
Non-Binary
Other
Non Disclose
Marital Status
Prefer not to say
Single
Married
Divorced
Separated
Widowed
Email
Phone Number
SSN
Address
Apt/Suite
City
State
Zip
Insurance and Income Information
Medicare Number
MassHealth Number
Estimated Monthly or annual income
Other Insurance Name
Other Insurance ID
PCP/Health Provider Information
Provider Name
Hospital Affiliation
Phone Number
Fax Number
Emergency Contact
Name
Phone Number
Cell Phone Number
Email
Relationship to Consumer
Address
Apt/Suite
City
State
Zip
Select One
HCP
Guardian
Alternate Contact
Is there anyone who should be contacted prior to (or instead of) the consumer being contacted
No
Yes
Alternate Contact Name
Alternate Contact Phone Number
Relationship to Consumer
Primary Language
If not English, is an interpreter needed?
No
Yes
Interpreter Name & Relationship
Interpreter Phone Number
Hospital or Nursing Facility Discharge
Was the consumer discharged from a hospital, nursing facility, or other institution in the past 90 days?
No
Yes
Hospital Name
Discharge Date
Reason for Admission
Nursing Facility name
Discharge Date
Reason for Admission
Was the consumer discharged with Certified Home Health Care?
No
Yes
Provider Name
List of Services
Major Medical Diagnoses & Describe The Consumer's Need
Major Medical Diagnoses & Describe The Consumer's Need
Services Requested
Home Care Services
Heavy Chore
Homemaking
Personal Care
Home Delivered Meals / Meal Preparation
Grocery
Laundry
Personal Emergency Response System (PERS)
Companion / Medical Escort
Respite
Home Delivered Meals
Home Delivered Meals
MassHealth Screening
Adult Day Health
Long Term Care (Nursing Facility)
Short Term Care (Nursing Facility)
MassHealth Waivers
Home Care Frail Elder Waiver (FEW)
Senior Care Options Frail Elder Waiver(SCO FEW)
MassHealth Programs(Must have MassHealth Standard or CommonHealth / Must Require physical assistance)
Personal Care Attendant (PCA)
Adult Foster Care (AFC)
Free Programs (Need to fill referral forms)
Family Caregiver Support Program
Options Counseling
Safety Questions
Does the consumer have any pets? If so, what type of pet(s)?
Are there any concerns that our worker should know before scheduling the home visit, such as a unsecured weapons, police activity, construction,etc.?
Has the consumer fallen within past 90 days?
Would you consider the consumer to be a fall risk?
Additional info
Request Type
Adult Foster Care (AFC)
Caregiver Support
Grocery
Group Adult Foster Care (GAFC)
Heavy Chore
Homemaking
Personal Care
Laundry
HDM / Meal Preparation
Medical Escort
Options Counseling
Personal Care Attendant (PCA)
Transportation
Trans
Any additional information
I certify that the information provided is true and correct to the best of my knowledge.
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