Who is in need of care?

Infant (age 0 – 2)

Child (age 3 – 18)

Adult female (age 19 – 64)

Adult male (age 19 – 64)

Senior (age 65 +)

How will we be able to contact you?

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Where will the patient need to receive home care?

(We provide care in the home, nursing facilities, and hospitals.)

Nassau

Suffolk

Queens

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Does the patient need care for any of the following?

Check all that apply

Diabetes Alzheimer’s Disease/Dementia Depression
Heart Disease Stroke Kidney Disease
High Blood Pressure Knee/Hip Replacement Cancer
Accident (an injury)

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What type of health insurance does the
patient have or is eligible for?

Check all that apply

Private insurance (e.g., GHI-HIP, Aetna, BlueCross BlueShield)

Out of pocket (private pay)

Medicaid

Medicare

None

NOT SURE

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How quickly will the care need to begin?

Immediately (within 24 – 48 hours)

This Week

This Month

NOT SURE

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This form is not available.

Access Home Care an approved provider of the NY State Department of Health Traumatic Brain Injury and Nursing Home Transition Diversion Waiver.

  © 2011 Access Home Care Inc. | 3100 Veterans Memorial Highway | Bohemia | NY 11716 | 631-476-3600