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Release of Information for Caregiver document sample
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IDAHO AREA AGENCY ON AGING INTAKE/REGISTRATION FORM 2
Area III Fax # (208) 322-3569 Date: 08/02/11 20:53 1
New
PROGRAM: Home Delivered Meals Homemaker Respite Other
Renewal
Provider Site
Original Reporter
Reporter Contact Info.
Last Name First Name Initial
Nickname Phone Number
Residential City, State
Address Zip
Mailing City, State
Address Zip
Date of Birth 0 Gender Male Female # of people living in household 1 2 3 4
Do you live in a rural area? Yes No Is your household monthly income below $0.00 Yes No
Is this person a caregiver? Yes No Has the client lost the primary Yes Is this an Adult Yes
caregiver in the household? No Protection Referral? No
Is this person a carereceiver? Yes No
Race/Ethnic Origin
American Indian/ Native Alaskan Black/African American Non-Minority (White, Non-Hispanic)
Asian Native Hawaiian/Pacific Islander White- Hispanic
Other Describe: Does the client speak English? Yes No
Marital Status If "No" what language:
Married Divorced Separated Widowed Single Is the client Homebound? Yes No
Yes Are they enrolled in VA
Is this person a Veteran? Did they serve War Time? Yes No Yes No
No medical center?
EMERGENCY CONTACT INFORMATION
Name: Name:
Home Mobile Home
Mobile Phone:
Phone: Phone:
Business Business
Phone: Phone:
Relationship: Relationship:
Was this person recently discharged from Hospital, Nursing Home or Rehab Facility? Yes No Date of Discharge:
Describe immediate
needs:
Primary Physician
Primary Physician
Phone #
Is there a medical condition which Yes If "Yes"
needs immediate intervention? No describe:
Administrative Use Only
Potential Services: SAMS ADL 0 SAMS IADL 0
High Nutritional Risk NO
Release of Information NO
Page 1 of 4 ID Reg Form 06-09E Check Box
FUNCTIONAL ABILITIES
ADL's Type of Needed Assistance Assistance Available
Identify the client's ability to: None Some Total Enough Some None
Eat Independently (feed self)
Get to and from toilet.
Walk by self.
Transfer from be or wheelchair by self
Dress & undress by self.
Bathe/wash hair by self.
IADL's Type of Needed Assistance Assistance Available
Identify the client's ability to: None Some Total Enough Some None
Prepare meals.
Transport or get transportation by self
Pay bills by self. (Manage Money)
Shop for food/personal items/run errands
Do laundry by self.
Clean House by self.
Seek emergency help by self.
Administer own medications
Perform outside chores & maintenance
Use the telephone
Client's need for supervison.
NUTRITIONAL HEALTH
Yes No
Does the client eat fewer than 2 meals per day?
Does the client eat few (less than 2) vegetables or fruits, or milk products per day?
Does the client have 3 or more drinks of beer, liquor or wine almost every day?
Does the client have tooth or mouth problems that make it hard to eat?
Does the client sometime not have enough money to buy food?
Does the client eat alone most of the time?
Does the client take 3 or more different prescribed or over-the-counter drugs per day?
Without wanting to, has the client lost or gained 10 pounds in the past 6 months?
Has illness or condition made the client change the kind and/or amount of food eaten?
Is the client not always physically able to shop, cook and/or feed themselves and has no help?
Is the client on a special diet or restricted foods?
If "Yes" explain:
0 0
Page 2 of 4 ID Reg Form 06-09E Check Box
CAREGIVER SECTION Must be completed: NO
Name of Care Yes No
Is the caregiver paid?
Receiver:
How is the caregiver related to Spouse Parent Child Grandchild
Care Receiver? Other Describe
List additional
caregivers and
support.
Does the care receiver need assistance with ADL's (eating,
Yes No 24 Hour Care? Yes No
toileting, walking, transferring, dressing, bathing)?
Does the care receiver live with Alzheimer's disease or related disorders with neurological and Yes No
organic brain dysfunction?
Is the care receiver a child with severe disabilities? Yes No
Does this person have Yes Name:
Financial Power of
Attorney? No Phone #:
Does this person have Yes Name:
a State appointed
Guardian? No Phone #:
HOME DELIVERED MEALS Start Date: PRIORITY SCORE RECAP
Age 0
Anticipated End Date:
Lives Alone 0
Lives in Rural Area 0
Income Below Poverty 0
Justify
Race/Ethnic Origin Miniority 1
Service:
Caregiver 0
English Speaking 0
Frozen Yes Adult Protection Referral 0
# of meals approved per week
Meals No ADL Total 0
IADL Total 0
Nutritional Health Total 0
Special Diet
Homebound 0
Total Priority Score 1
Units of service will only be reimbursed if the consumer meets eligibility criteria for the specified program(s).
Consent release: I do authorize Yes I do NOT authorize No the release of information to aging network.
I understand this information must be updated at least annually and will be released to the Area Agency on Aging and providers
associated with Area Agency on Aging for sole purpose of assisting me to receive services and benefits to which I may be
entitled.
Client or Authorized Representative Signature Date
Interviewer Signature Date
AAA Reviewer Signature Date
Comments:
0 0
Page 3 of 4 ID Reg Form 06-09E Check Box
Client Name: 0 0 Referal to Case Management Yes No
Require minimal assistance with one or more ADLs or IADLs;
Require multiple services from health/social services providers;
Unable to obtain the required health/social services for themselves;
Lack available family or friends who can provide the needed assistance;
Notes:
Page 4 of 4 ID Reg Form 06-09E Check Box
