Intake Referral Form Page 2
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1
2Billing Information
Do you have State Medical Assistance? If yes, MA#: ___________________ State: ____
County of Service: ________________________
Do you have a Waiver? If yes, what type?: ___________________________________
County Worker: _____________________ Phone#: ________________________
Private Insurance: No
Yes
Company: ______________________________
Policy/ID#: _______________________ Group#: _______________________
Policy Holder’s Name: ______________________________ Policy Holder Date of Birth: ___________
Insurance Effective Date: ________________
Company the policy is provided by: ____________________________________
Private Insurance: No
Yes
Company: ______________________________
Policy/ID#: _______________________ Group#: _______________________
Policy Holder’s Name: ____________________ Policy Holder Date of Birth: ___________
Insurance Effective Date: ________________
Company the policy is provided by: ____________________________________
Does client go to school? No
Yes
School Name: _____________________________________
School contact: _________________________________ Phone #: ______________________
Private Pay: No
Yes
Responsible for Payment: ____________________________________
Address and Phone # of Payee: _________________________________________________
_________________________________________________
_________________________________________________
House Rules
• Parking:
Where would you like the staff to park? _______________________________________
If street parking is requested, are there any restrictions to this? (ie. No parking at night, Snow
emergency routes) ________________________________________________________
• Entrance/Exit:
Where would you like the staff to enter and exit the home? __________________________
Would you like the door bell rung? ____________________________________________
Would you like the door locked and if so, when? __________________________________
• Personal Belongings:
Where would you like the staff to place their personal items? _________________________
Would you like the nursing staff to remove their shoes when entering? __________________
• Meals: Staff are expected to bring their own food
May food be stored in the refrigerator? _________________________________________
May the stove/microwave be used for heating items? _______________________________
May the kitchen be used to wash and rinse dishes? _________________________________
• House Limits:
Where can the staff and clients move about in the house? ____________________________
Are there specific areas which are off limits? _____________________________________
Other Notes:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Email:
Fax: (763) 633-3808
Email
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Any questions? Call: (866) 214-3800
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Parent category: Medical