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APAL Patient Inquiry Form

Thank you for giving us a chance to help!

Salutation:
Name:*
FirstLast
Email:*
Zip Code:*
Primary Phone:
Secondary Phone:
Preferred Method of Contact?*
Best time to call:
Please provide the desired location for the service(s) or product(s) to be provided:*
Zip:*
Please select any services that you believe are required for the Care Recipient: (Please select all that apply)
- Adult Day Care / Respite Care
- Assisted Living
- Assistance with Long Term Care Insurance Claim Filing
- Companion Services
- Geriatric Assessment / Evaluation
- Home / Safety Monitoring
- Homecare (Non-Medical)
- Homemaker/ House Cleaning
- Hospice Services
- Live In Home Care
- Meal Preparation
- Personal Care (e.g. Bathing, Toileting or Grooming)
- Transportation Non-Medical (e.g. Errands, Shopping)
What funding source will be the primary payer for the services or products? (Please select one)
- Private pay
- D&E Waiver/Private - Amerigroup
- D&E Waiver/Private - Evercare
- Mia Via / Private
- VA / Private
How much have you budgeted for these "out-of-pocket" expenses? (Please select one)
- Less than $250 per week
- $250 to $500 per week
- $500 to $1,000 per week
- $1,000 to $1,500 per week
- Over $1,500 per week

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