A Better Home Health Care Serving Canton Ohio
 

How is billing done and is it tax deductible?

A Better Home Health Care typically bills all third-party payment directly to the insurance or program involved. Our privately paid clients are delivered a multi-copy invoice on weekly basis, providing a copy for the return payment and a copy for your own records....

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This form is our general information initial referral form. If you are already familiar with the home health care system, know whether or not you may be covered by insurance, Waiver IV or other program, you may want to complete our Intake Form instead.
General Information
Your Name
First:
Last:

Client Name (If different from above)
First:
Last:

Address
Line1:
Line2:
City:
State:
Zip/Postal Code:

E-mail:

Phone Numbers
Home:
Other:
Best time to contact you:

Personal Information
Date of Birth, Age and Gender
..... .....
Preferred Hospital
 Social Security Number (Optional)
Medical Information
Diagnosis (es)


Additional Information


Functional Limitations


Financial Responsibility

Privately Paid Waiver IV
Insurance Policy Other
Passport Program Unsure
Support Information

Primary
Physician
Phone
Address
 City
State
 Zip

Secondary
Physician

Phone
Address
 City
State
 Zip

Nearest
Relative

Phone
Address
 City
State
 Zip
Care Required
** This is only to help us assess your situation. There is no obligation to use these hours / services.
.
Type of Care Days Times
Personal Care
Homemaker
Other


When do you need care to begin?
Directions or Other Information
Let us know any special directions or instructions.

Thanks for considering A Better Home Health Care North, Inc. / A Better Home Health Care South, Inc.
One of our Office or Management Team will be in contact with you soon !
* Please press "send" only once.
 
Copyright 1999-2007
A Better Home Health Care North, Inc. / A Better Home Health Care South, Inc.