Referral Form

All About You Home Care

For a free consultation:

(610) 553-5595

allaboutyouhomecare@outlook.com

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Referral Guidelines

After the referral is received, the individual will be contacted via phone within 1-3 business days. PA IEB may use an automated dialer to make contact with these individuals. Please note that an application will not begin until the individual expresses to IEB staff interest in applying and the individual has Medical Assistance or completes and returns an application for financial eligibility for Long Term Services to PA IEB.

If “Referral Made By” section is completed by the Area Agency on Aging or by a LIFE provider, then the application is started. The applicant is not called to confirm interest in applying for waiver and / or LIFE program services.

Mail to:

P.O. Box 61560, Harrisburg, PA 17106

Call toll-free:

1-877-550-4227

Fax To

1-888-349-0264

Email to:

PAIEB@maximus.com

Applicant Information

Your Name(Required)

First Middle Last

Recipient ID Number (Medicaid recipients only):

Date of birth (mm/dd/yyyy):

MM slash DD slash YYYY

Social Security Number:

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email address:(Required)

Phone number:(Required)

Alternate phone:

Please correspond with the additional contact(s) below to begin process, rather than the applicant. Note: Applicant or legal representative must sign consent below.

Additional Contacts

(add another page, if needed)

Contact name or entity:

Contact type:

Family

POA

AAA

Social Worker

Phone number:

Consent

Signature of applicant authorizing sharing of information with this contact:

Contact name or entity:

Contact type:

Family

POA

AAA

Social Worker

Phone number:

Consent

Signature of applicant authorizing sharing of information with this contact:

Referral Made By

Name:

Agency:

Date of referral (mm/dd/yyyy):

MM slash DD slash YYYY

Phone number

Consent

Above staff has confirmed that the referral has requested that an application be initiated on their behalf. (Check box to confirm.)

Physician Information

Physician name:

Physician street address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone number:

Fax number:

Nursing Home Transition Program

NHT Coordinator:

Agency:

Call Today

Phone (610) 553-5595

Email

allaboutyouhomecare@outlook.com

24 Hour Care Available

It’s So Fast & Easy

We understand no two clients’ situations are the same, so no two clients’ care plans are the same. After you contact us All About You Home Health Care, a Nurse will visit with you to talk about what you are looking for and answer your questions.

Get in touch

(610) 553-5595

allaboutyouhomecare@outlook.com

753 West Cheltenham Ave Unit C Melrose Park PA 19082

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Referral Guidelines

Mail to:

Call toll-free:

Fax To

Email to:

Referral Form

Applicant Information

Additional Contacts

Referral Made By

Physician Information

Nursing Home Transition Program

Call Today

Email

24 Hour Care Available

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