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Employee Caregiver Support Services
Virtual Care Management Service
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Virtual Care Management Service Application Form
Payment
Virtual Care Management Membership Service: $59.99
Name on card
*
Credit Card
*
Credit Card
Credit Card
Credit Card
Month
1
2
3
4
5
6
7
8
9
10
11
12
Credit Card
Year
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
2031
Credit Card
Virtual Care Management Service
Demographics
Diagnosis – please list all known diagnoses
*
Client Name
*
Address
*
Address
house number and street
house number and street
suite or apartment #
suite or apartment #
City
City
State
Alabama
Alaska
Arkansas
Arizona
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Zip Code
Phone
*
Email
*
Date of Birth
*
Place of Birth
*
Marital Status
*
Single
Married/Widowed
Divorced/Separated
Number of Children
Select
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Number of Grandchildren
Select
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Number of Siblings
Select
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Insurance
Medicare?
*
Yes
No
Medicaid?
*
Yes
No
Veteran?
*
Yes
No
Did you serve during wartime?
*
Yes
No
Honorable discharge?
*
Yes
No
Are you a surviving spouse of a deceased veteran?
*
Yes
No
Cognitive Evaluation
Is the patient able to make decisions?
*
Yes
No
Provide detail for a “no” response:
*
Oriented to:
*
Person
Place
Time
Provide detail for any checked boxes:
*
Behaviors
*
Anxious
Agitated
Wandering
Verbally abusive
Socially inappropriate
Exit seeking
Sun downers
Not applicable
Provide detail for any checked behaviors:
*
Medical Equipment and Information
Medical Equipment (used daily)
*
Wheelchair
Walker
Cane
Hospital bed
Bedside commode
Shower chair
Chair rail
Not applicable
Other
Other
Provide detail for medical equipment:
*
Date of last hospitalization
Current living situation
*
List all medications currently prescribed (completing this section will help us make better decisions regarding your/your loved ones care):
List all allergies (completing this section will help us make better decisions regarding your/your loved ones care):
List any safety concerns:
*
Advance Directives
Do you have a durable power of attorney?
*
Yes
No
Do you have a health care surrogate?
*
Yes
No
Do you have a guardian?
*
Yes
No
Do you have a living will?
*
Yes
No
Do you have an Elder Law Attorney?
*
Yes
No
Who are the people who provide support to you?
*
Submit
