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Medicaid Caps & Cuts
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FAQ
Links
Consumers Affordable Resource for Energy (CARE)
Caregiver Resources
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Senior Resource Directories
Programs & Services
Information & Assistance
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Health Access Information
MI Choice Waiver Program
Medicare/Medicaid Assistance (MMAP)
Independent Living Programs
Health & Wellness Programs
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Calendar
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Senior Power Day
Big Wheels Deliver Meals
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Fraud, Waste, & Abuse
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Service Request
Is the senior informed of this referral?
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Is the client able to answer for themselves?
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Medicaid
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Have you been hospitalized in the last 30 days?
Yes
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If so, where?
Current Diagnosis
Are you currently in the hospital?
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Anticipated discharge date
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Preliminary Information
Is there currently someone paid to provide assistance in the home?
Yes
No
If yes, whom?
Do you receive oxygen 24/7?
Yes
No
Do you live alone?
Yes
No
If no, with whom?
Do you have significant memory loss?
Yes
No
Are you able to get out of bed?
Yes
No
Are you able to prepare your own meals?
Yes
No
Do you currently receive Dialysis?
Yes
No
Are you able to complete personal care tasks independently? (grooming, dressing, bating, toiling, etc.)
Yes
No
Do you currently drive?
Yes
No
Do you currently use any of the following assistive devices?
Wheel Chair
Cane
Walker
Lift
Other
Do you have a history of mental illness?
Yes
No
If yes, please explain.
Contact/Referral Information
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Email
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Referred by (Name)
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Your Email
*
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Other Comments
Other documents to support your request if applicable.
Would you/contact person like a referral status update?
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If yes, please specify the email where the status updated should be directed.
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