McCormick's Compassionate Care LLC

👤

Client Information

Please provide the client's personal details.

📋 Completed By *

Client Guardian Staff Assistance

First Name *

Last Name *

Date of Birth *

Gender

SSN (Last 4 Digits)

Street Address *

City *

State *

ZIP Code *

Phone Number *

Email Address

Preferred Language

Marital Status

🏠 Authorized Representative / Legal Guardian

Representative Name

Relationship to Client

Representative Phone

Representative Email

🏥

Medical & Emergency Information

Help us provide safe, informed care.

🩺 Primary Physician

Physician Name *

Physician Phone *

Physician Address / Clinic

💊 Medical Information

Current Medications

Known Allergies

Current Medical Conditions / Diagnoses

Do you use any assistive devices?

Wheelchair Walker Cane Oxygen Hearing Aid None

Special Instructions / Care Notes

🚨 Emergency Contacts

ℹ️ Please provide at least one emergency contact who can be reached if you are unable to communicate or in case of an emergency.

Emergency Contact #1

Full Name *

Relationship *

Phone *

Emergency Contact #2

Full Name

Relationship

Phone

🚨 Emergency & Safety Plan

Emergency Plan

Primary Hospital *

Safety Risks

Fall Risk Wandering Behavior Concerns None

🩺 Functional Assessment

Toileting Assistance

Independent Needs Assistance Total Care

Incontinence / Briefs (Pull-Ups)

None Occasional Frequent Requires Staff Assistance

Additional Details (Optional)

💜

Services & Payment Information

Select the services you need and your payment method.

🛎️ Services Requested

Select all services that apply to your care plan:

Personal Support Respite Care Companion Care Medication Reminders Well-Check Visits Errands & Shopping Shuttle Bus Transportation Homemaker / Housekeeping Post-Hospital Recovery Notary Services Life Skills Development

Preferred Days

Mon Tue Wed Thu Fri Sat Sun

Preferred Time

How did you hear about us?

📅 Service Start

Requested Start Date *

💳 Payer / Payment Method

Select Your Payment Type *

Private Pay VA Pay Medicaid Waiver Long-Term Care Insurance Contracted Company (Hospital/Dialysis)

💳 Payment Authorization

Payment Responsibility *

Client Guardian Other

Payment Method *

Card Cash Invoice

📋

Consents & Acknowledgments

Please review and agree to the following.

✅ Consent for Services

I hereby authorize McCormick's Compassionate Care LLC to provide the home and community-based services I have selected. I understand that services will be rendered by trained staff under the supervision of the agency's Administrator. I may revoke this consent at any time by providing written notice to the agency.

I agree to the Consent for Services *

🚑 Emergency Medical Treatment Consent

In the event of a medical emergency during service delivery, I authorize McCormick's Compassionate Care LLC staff to contact emergency medical services (911) on my behalf and to share pertinent medical information with emergency responders as needed to ensure my safety.

I agree to the Emergency Medical Treatment Consent *

🔒 HIPAA Notice of Privacy Practices

McCormick's Compassionate Care LLC is committed to protecting your personal health information (PHI) in accordance with HIPAA regulations. Your PHI will only be used for treatment, payment, and healthcare operations unless otherwise authorized by you. You have the right to request access to, amendment of, or restrictions on the use of your PHI. A full copy of our Privacy Practices is available upon request.

I acknowledge receipt of the HIPAA Notice of Privacy Practices *

📷 Photo / Media Release (Optional)

I grant McCormick's Compassionate Care LLC permission to use photographs or images of me for promotional and educational materials, including social media, brochures, and the agency's website. I understand I may revoke this consent at any time in writing.

I consent to Photo/Media Release I do NOT consent

🚐 Transportation Waiver & Agreement

If utilizing non-emergency shuttle bus transportation services provided by McCormick's Compassionate Care LLC, I acknowledge and agree to the following: (1) I will remain seated with my seatbelt fastened at all times while the vehicle is in motion; (2) I will follow all safety instructions provided by the driver; (3) the agency is not responsible for injuries resulting from my failure to comply with safety rules; (4) I will be ready at my designated pick-up location at the scheduled time; (5) the agency's shuttle bus is ADA-compliant and accommodates wheelchairs and mobility devices. I release McCormick's Compassionate Care LLC from liability for delays caused by traffic, weather, or other circumstances beyond the agency's control.

I agree to the Transportation Waiver (if applicable)

⚖️ Client Rights & Responsibilities

Your Rights: You have the right to be treated with dignity and respect; to receive services without discrimination; to participate in your care plan; to privacy and confidentiality; to voice grievances without fear of retaliation; to be informed of service costs; to refuse services at any time; and to access your records upon request.

Your Responsibilities: You agree to provide accurate personal and medical information; to treat staff with respect; to notify the agency of schedule changes within 24 hours; to maintain a safe environment for caregivers; to communicate any concerns promptly; and to comply with your agreed-upon care plan.

I acknowledge my Rights and Responsibilities *

📝 Grievance / Complaint Policy

McCormick's Compassionate Care LLC values your feedback. If you have a concern, you may: (1) speak directly with your caregiver; (2) contact the office to speak with an administrator; (3) submit a written grievance; or (4) contact external agencies if the issue is not resolved. All complaints are reviewed within 5 business days, and we will work to resolve the matter promptly and fairly. You will never face retaliation for filing a grievance.

I acknowledge the Grievance / Complaint Policy *

📅 Attendance, Cancellation & No-Show Policy

Please notify the agency at least 24 hours in advance if you need to cancel or reschedule a service visit. Repeated no-shows or late cancellations may result in fees (for private pay clients) or a review of your service plan. Inclement weather or emergency closures will be communicated as soon as possible.

I acknowledge the Attendance, Cancellation & No-Show Policy *

⚕️ Non-Medical Services Disclaimer

McCormick's Compassionate Care LLC provides non-medical home care services only. Staff do not perform skilled nursing or medical procedures.

I understand this is non-medical care *

✍️

Signatures & Submission

Sign below to complete your enrollment.

ℹ️ By signing below, I certify that all information provided in this enrollment form is true and accurate to the best of my knowledge. I acknowledge that I have received, reviewed, and understand all policies, consents, and agreements listed above, and I agree to the terms of service provided by McCormick's Compassionate Care LLC.

Client / Authorized Representative Signature *

Sign above using your mouse or finger

Printed Name *

Date *

Relationship to Client (if representative)

🏢 FOR OFFICE USE ONLY

This section is to be completed by agency staff only.

Intake Reviewed By

Date Reviewed

Assessment Completed

Yes No Pending

Care Plan Created

Yes No Pending

Staff Assigned

Start Date Approved

Agency Representative Signature

Agency representative sign above

Client Information

Medical & Emergency Information

Services & Payment Information

Consents & Acknowledgments

✅ Consent for Services

🚑 Emergency Medical Treatment Consent

🔒 HIPAA Notice of Privacy Practices

📷 Photo / Media Release (Optional)

🚐 Transportation Waiver & Agreement

⚖️ Client Rights & Responsibilities

📝 Grievance / Complaint Policy

📅 Attendance, Cancellation & No-Show Policy

⚕️ Non-Medical Services Disclaimer

Signatures & Submission

Enrollment Submitted!