Affordable Care Agency

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Client Application

Care Liaisons assigned to each client and their family.

How did you find out about us?

Have you already spoken to someone from Affordable Care?

IF YES,

Person Who Will Be Receiving Care

(we do not contact them)

Client's Information

Physician :

Specialist (e.g. Neurologist)

General Practitioner

Schedule:

(4 Hrs minimum per visit, 2x visit a week)

Total Hours

Start Time

End Time

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Service Location:

If in the Facility/Hospital:

Clients Pre-Requisites for Care Provider Service:

(Examples: Driving Care Provider, Care Provider experienced with Uber, Care Provider required to fill out paperwork, Care Provider who speaks Spanish etc.)

Primary Point of Contact:

(This will be the person we call now to coordinate care)

In case of emergency, Care Provider should call:

Communication Section

Would you like to include multiple family members in our communication with you?

Group Text:

Name

Phone No.

Group Email:

Name

Email

Others:

Client's Billing

Insurance:

If yes:

(LTC is different than medical insurance, unfortunately, medical insurance doesn’t usually cover Care Providers, this is why we try to be affordable, and for most client this is out of pocket expense. Long Term Care insurance is typically sold by a Life insurance agent).

Payment Options:

We only accept:

Debit Card, Check/Electronic Check, Electronic Fund Transfer(Zelle)

Who will sign the service agreement?

If this form is being filled out on behalf of the Family/Client by a 3rd Party, Please Provide Your Name and Contact Info