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APPLICATION FOR HOME HEALTH SERVICES2780 28th AvenueGreeley, CO 80634970.339.2444APPLICATION FOR HOME HEALTH SERVICESDESCRIPTION OF SERVICESThe following services are offered under Medicare/Medicaid home health care guidelines:1. Private Duty Skilled Nursing: Face-to-face skilled nursing provided by a Licensed Nurse (LPN or RN)which is more individualized and continuous than nursing care available under routine home healthbenefits, hospitals or nursing facilities. Appropriate clients may be technology dependent (i.e.,prolonged IV administration and nutrition support). Private duty skilled nursing requires a specific levelof approval.2. Skilled Nursing: Skilled nursing services provided by a Registered Nurse (RN) or Licensed PracticalNurse (LPN) under the direction of an RN.3. Skilled Certified Nurse Aide: Licensed Certified Nurse Aide (CNA) provides skilled personal care foractivities of daily living under the direction of an RN.4. Home and Community Based Services (HCBS): Personal Care and Homemaking services which includesunskilled care such as laundry, housekeeping, meal preparation and shopping.Note: Physical, Occupational and Speech Therapy are not provided under Home Care Services.The following services are NOT provided under home health care:Apartment rent, utilities, phone, cable, furniture and/or home furnishings, clothing, medication, medicalequipment, lab testing, home care supplies, cleaning or laundry supplies, groceries, social entertainment,transportation, school tutoring or accompaniment to outside activities.Clients who receive HCBS services must provide their own funds for groceries, supplies and laundry.DOCUMENT CHECKLIST:These documents must be provided in order to be considered for our Home Health services.Latest history and physical from your primary care physicianIf inpatient, last progress note from attending MDDischarge summary (if inpatient acute or SNF)Current medication list provided by your pharmacy or physician (if inpatient current MAR required)List of regularly used over-the-counter medications
APPLICATION FOR HOME HEALTH SERVICESAPPLICANT INFORMATIONApplicant Name:Preferred name:Date of Birth:Current Address:City: State: Zip:Home Phone: Cell Phone:E-mail:Height:Weight:Gender: ( ) M ( ) FPreferred Language:Preferred Language for Written Communication:Primary Diagnosis:Date of Diagnosis:If primary diagnosis is related to an injury, please provide the date of injury:Secondary Diagnoses (List all):Name of Primary Care Provider:Address:Phone:Date of last PCP visit:Are you under the care of any other medical professionals?Yes NoIf yes, please list name of MD and specialty (Cardiology, Neurology, Mental Health, etc.):Do you currently have a paid or volunteer job?Yes NoIf yes, is it ( ) full-time( ) part-time( ) seasonalCurrent employer (if applicable):Level of Education:Marital Status:Children: Yes NoName of person completing application if other than applicant:Relationship:Home Phone: Cell Phone:E-mail:
APPLICATION FOR HOME HEALTH SERVICESFAMILY/RESPONSIBLE PARTY’S INFORMATIONWho would you want us to contact on your behalf in case of an emergency (Emergency Room visit, Urgent Care visitor other urgent matters)?Name:Relationship:Current Address:City: State: Zip:Home Phone: Cell Phone:E-mail:Do you have any of the following (please check all that apply)?( ) Legal Guardian( ) Conservator( ) Power of AttorneyIf yes, please provide the following information for the individual/s in these roles:Name:Current Address:City: State: Zip:Home Phone: Cell Phone:E-mail:Who will assist you in case of an emergency, such as being sent to the hospital or needing to see a doctor quickly?Name:Current Address:City: State: Zip:Home Phone: Cell Phone:E-mail:Who will assist you with non-emergency needs that you may have such as picking up medications, making doctorappointments, arranging transportation, etc.?Name:Current Address:City: State: Zip:Home Phone: Cell Phone:E-mail:Name:Current Address:City: State: Zip:Home Phone: Cell Phone:E-mail:
APPLICATION FOR HOME HEALTH SERVICESWho will assist you to manage your doctors’ appointments, including transportation, if needed?Name:Current Address:City: State: Zip:Home Phone: Cell Phone:E-mail:PAYOR INFORMATIONDo you have Medicaid? Yes No If yes, Medicaid # State:Do you have Home and Community Based Services (HCBS)? Yes NoIf yes, in what county? Phone number:Who is your HCBS Case Manager?Do you have Medicare? Yes No Part A Part BIf yes, list your Medicare #:
APPLICATION FOR HOME HEALTH SERVICESMEDICAL INFORMATIONCan you manage your own medication organization, schedule and storage?YesNoIf no, which part of your medication management do you need assistance with?Do you need assistance with taking your medications?YesNoIf yes, which medications (pills, injections, patches, eye drops, etc.)?Have you had or do you currently experience seizures?YesNoIf yes, what type of seizures?Are they controlled by medication?YesNoHave you been injured as a result of a seizure?YesNoDo you use any safety devices related to seizures?YesNoIf yes, what device?Can you go into the community unassisted and be safe?YesNoDate of last seizure:Have you ever had a stroke?YesNoIf yes, please provide the date of stroke:Please list any deficits from the stroke (weakness, slurred speech, difficulty swallowing, etc.):Do you have problems with your vision?YesNoIf yes, please explain:Do you wear glasses or contact lenses?YesNoDo you have any hearing problems?YesNoIf yes, please explain:Do you use hearing aids?YesNoIf yes, can you manage them yourself?YesNoAre you incontinent or do you experience episodes of incontinence?YesNoIf yes, please select which type: ( ) Bladder (Urine) ( ) Bowel (Fecal) ( ) BothHow often (times per day on average) do you experience episodes of incontinence?Are you able to perform your own pericare/incontinence care?YesNoIf no, how much assistance do you need?( ) Stand by Assist (set up supplies only)( ) Partial Assist (set up supplies, remove clothing/bedding, assist with positioning, some assistance withhard to reach areas)( ) Full Assist (supplies, full pericare, clothing/bedding change, repositioning, bath/shower if needed)Do you have a urinary catheter?YesNoIf yes, what kind (suprapubic, indwelling, condom)?How often is your catheter changed?Are you able to perform your own catheter changes?YesNo
APPLICATION FOR HOME HEALTH SERVICESDo you have an ostomy for bowel elimination?If yes, are you able to perform your own ostomy care?Do you currently use a bowel program?If yes, how many times per week?Does your bowel program include digital stimulation?YesYesYesNoNoNoYesNoDo you have any eating/swallowing concerns?YesNoIf yes, please explain:Have you choked in the past?YesNoDo you have a history of aspiration pneumonia?YesNoIf yes, provide the date of the most recent episodeDo you require your liquids to be thickened?YesNoDo you require your foods to be chopped, minced or pureed?YesNoDo you require monitoring while you eat?YesNoDo you use any communication devices?YesNoIf yes, please explain:What forms of communication do you use?Do you have any chronic respiratory conditions (asthma, COPD, bronchitis, sleep apnea, etc.)?If yes, is it controlled with medications?Do you currently use oxygen?Do you currently use a CPAP machine?YesYesYesYesNoNoNoNoDo you experience chronic pain?YesNoIf yes, type and location:Do you experience muscle spasms?YesNoIf yes, location and frequency:How do you currently manage your pain (medication, physical therapy, alternate therapies, etc.)?Do you smoke?YesNoIf yes, how much and how often?Do you drink alcoholic beverages?YesNoIf yes, how much and how often?Do you have a history of alcohol or drug abuse including medical and/or recreational marijuana?YesNoIf yes, please explain:Have you received treatment for alcohol and/or drug abuse?Yes NoIf yes, where and when?Do you use illegal street drugs?YesNoIf yes, what and how often?List any surgeries in the past 12 months:
APPLICATION FOR HOME HEALTH SERVICESHave you visited the ER in the past 12 months?Yes NoIf yes, how many times:List reason/s for visits:Number of hospital visits in the past 12 months:Date of last admission:Reason for last admission:Do you have any implanted medical devices?YesNoIf yes, please list type and locationDo you have diabetes?YesNoIf yes, Type 1 or Type 2?Managed with medications? If yes, what kind?Do you take insulin?If yes, how many times per day do you require insulin?Are you able to administer your own insulin injections?YesNoYesNoDo you require daily blood sugar monitoring?If yes, how many times per day?Can you perform your own blood sugar checks?YesNoYesNoDo you use an insulin pump?If yes, are you able to manage your own pump refills and maintenance?Are you able to perform diabetic foot checks on your own?YesYesYesNoNoNoDo you have any chronic infections: Urinary, pneumonia?YesNoDo you currently have any type of unhealed skin wounds anywhere on your body?YesNoIf yes, please provide type (surgical, bed sore, etc.), location and date of occurrence:Can you identify if you are getting sick?YesNoDo you require 24hr/day support?YesNoIf yes, who will provide this support?Do you go into the community unassisted?YesNoDo you receive any mental health supports?YesNoIf yes, please explain:Which of the following equipment do you use?( ) Hospital bed( ) Bedside commode/toilet riser( ) Bedside lift/sling( ) Adaptive eating device( ) Electric wheelchair( ) Fireman’s pole( ) Electric medication minder ( ) Other DME not listed( ) Manual wheelchair( ) Communication device( ) Shower chair/bench
APPLICATION FOR HOME HEALTH SERVICESCLIENT ACKNOWLEDGMENTI acknowledge and understand that this is an application for Home Health services provided by Adeo, that Adeodoes not provide round-the-clock care or 24 hour/day support, is a Home Health Agency and is not a licensedassisted living facility.I understand that Home Health visits are timed, scheduled and pre-approved visits.I understand that I must be independent in my own home or be responsible for obtaining/arranging for anothersource of support to be available to me if I need/require round-the-clock care.SignatureDate
equipment, lab testing, home care supplies, cleaning or laundry supplies, groceries, social entertainment, transportation, school tutoring or accompaniment to outside activities. Clients who receive HCBS services must provide their own funds for groceries, supplies and laundry. DOCUMENT CHECKLIST: These documents must be provided in order to be considered for our Home Health services .
