Request an In-Home Health Care Assessment

Home Health Care provides in-home health care assessment to individuals who meet the criteria for services including:

Are receiving Medicare/Medicaid benefits.

Homebound, which is defined as:

Leaving home requires a considerable taxing effort.

The person has a condition due to an illness that restricts his/her ability to leave home except with supportive devices such as crutches, canes, wheelchairs, walkers or assistance from another person.

It is medically contraindicated that the person should leave his/her home.

Absences from home are generally infrequent and for a short duration, usually for the purpose of receiving medical treatment, attending day care centers or services.

_______________________________________________

To request an in-home assessment please submit the following information. Those individuals who meet the criteria for home health care will be contacted by a Nurse within one business day.

_______________________________________________

FirstName Last Name

Street Address City State

Zip Code: Home Telephone

Email Address

What does the client need help with?

Check all that apply:

Physical Therapy

Personal Care

Dementia Care

Pulmonary Care

Cardiac Care

Fall Prevention

Medical Social Services

Medication Administration Management

Other:

Name of Primary Care Physician

Please fill out the information below if you are not submitting this form for yourself but for a family member or friend:

FirstName Last Name

Street Address City State

Zip Code: Home Telephone

Email Address

Do we have permission to contact the person that you are referring?

Yes No

Senior Home Support
600 S. Lincoln St.
Augusta, MI 49012
Phone 1-888-594-5787
Fax 269-731-5246