Hope House Home Healthcare

*First Name:

Middle Initial:

*Last Name:

*Email:

*Phone:

Social Security Number

*Address:

*City:

*State:

*Zip:

*Medicaid or Insurance ID Number:

Alternate Phone:

*Primary Spoken Language:

*Gender:

Male

Female

*Are you receiving services from any other home health or personal care agency?

yes

no

If yes, which agency?

*Do you have your own Caregiver?

yes

no

If yes, please list the name of your Caregiver:

What is your Caregiver’s relationship to you?

*If you are requesting Supportive Home Care, please tell us what you need help with: (Check all that apply)

*If you are requesting Personal Care Services, please tell us your diagnosis or condition: (Check all that apply)

*If you are requesting Personal Care Services, please tell us what you need help with: (Check all that apply)

*Primary Care Physician Name:

*Phone:

Fax:

*Address:

*City:

*State:

*Zip:

*Is there a person authorized to represent you and sign all forms on your behalf?

yes

no

If yes, please list their full name:

Relationship:

Phone:

Address:

City:

State

Zip:

Should all correspondence be sent to this person?

yes

no

*I certify that the information I provided on and in connection with this form is true and accurate to the best of my knowledge. I also understand that any false statements or deliberate omissions on this form may result in a denial of services.

yes

*Electronic Signature Agreement. By selecting the "I Accept" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. By selecting "I Accept" you consent to be legally bound by this Agreement's terms and conditions. You further agree that your use of a keypad, mouse, or other device to select an item, button, icon, or similar act/action, or to otherwise provide information to Hope House Home Healthcare or in accessing or making any transaction regarding any agreement, acknowledgement, consent terms, disclosures or conditions constitutes your signature (hereafter referred to as "E-Signature"), acceptance and agreement as if actually signed by you in writing. You also agree that no certification authority or other third-party verification is necessary to validate your E-Signature and that the lack of such certification or third-party verification will not in any way affect the enforceability of your E-Signature or any resulting contract between you and Hope House Home Healthcare. You also represent that you are authorized to enter into this Agreement for all persons who own or are authorized to access any of your accounts and that such persons will be bound by the terms of this Agreement. You further agree that each use of your E-Signature in obtaining employment with Hope House Home Healthcare constitutes your agreement to be bound by the terms and conditions of Hope House Home Healthcare.

I Accept

*Client or Representative Signature:

*Date:

Provider Referral

Contact Us

Useful Links

Contact info

Blytheville, AR 72315

Phone: (870) 549-3882

Fax: (870) 549-3883

Email: info@hopehouseonline.com