Refer to LifeCare Alliance

Online Referral Form

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Referral Process

Services

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Step 1 of 19

This application is secure. All submitted information is secured with bank-level encryption to ensure privacy and compliance with federal HIPAA regulations. By completing this referral application, you attest that you are either the client or are authorized by the client to submit personal/protected information to LifeCare Alliance on their behalf. Information collected in this referral application will become part of the client’s file at LifeCare Alliance.

What is the source of this referral ?*

Referring Agency

Physician's Office

Self

Family

Will you be completing this form solely for the individual, or also for the individual's partner ?*

Individual

Individual's Partner

Do you want to learn about services provided by Central Ohio Diabetes Association.

These educational services equip youth and families in Central Ohio with the knowledge and skills necessary to successfully manage the challenges of diabetes. Programs include summer diabetes camps.

Yes

LifeCare Alliance Employee Name*

Your Email Address*

Patient Information

Name*

First Last

Date of Birth

MM slash DD slash YYYY

Phone*

Address*

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

Emergency Contact

First Last

Emergency Contact Relationship

Emergency Contact Phone

Patient Information

Applicant 1's Name*

First Last

Applicant 2's Name*

First Last

Applicant 1's Date of Birth

MM slash DD slash YYYY

Applicant 2's Date of Birth

MM slash DD slash YYYY

Applicant 1's Phone*

Applicant 2's Phone*

Applicant 1's Email

Applicant 2's Email

Applicant 1's Address

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

Applicant 2's Address

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

Is Applicant 1's address same as Applicant 2?

Yes

Applicant 1's County of Residence

Applicant 2's County of Residence

Emergency Contact

First Last

Emergency Contact Relationship

Emergency Contact Phone

Patient Information

Is the patient a veteran, spouse of a veteran, or surviving spouse of a veteran?*

If yes, we will request a copy of the patient's DD214.

Yes

Unknown

Is the patient a Franklin County Senior Options recipient?*

Yes

Unknown

Franklin County Senior Options Case Manager Name

First Last

Services Received through Franklin County Senior Options

Is the patient a PASSPORT/MyCare Ohio(Aetna/Molina)/Department of Developmental Disabilities recipient?

Yes

Unknown

Case Manager Name

First Last

Phone

Services Being Received Through Waiver

Does this patient already receive home-delivered meals?*

Yes

Unknown

Current Home-Delivered Meal Provider

Insurance Information

Does the patient have medical insurance?

Yes

Unknown

Primary Insurance Carrier

Primary Insurance Member ID

Primary Insurance Group #

Does the patient have secondary medical insurance?

Yes

Unknown

Secondary Insurance Carrier

Secondary Insurance Member ID

Secondary Insurance Group #

Services Being Requested

In order to determine if Home-Delivered Meals is right for you or your loved one, please answer the following questions. (If you are completing these questions on behalf of someone, please answer as appropriate for the person requesting Home-Delivered Meals.)

Meals-on-Wheels

Meals-on-Wheels offers a great option for those who are no longer able to cook for themselves. Home-delivered meals from LifeCare Alliance are nutritionally balanced and provide a variety of menu types with lots of tasty choices. LifeCare Alliance delivers meals in Franklin, Madison, Marion, Champaign, and Logan Counties. To participate, recipients must meet a series of eligibility criteria.

Home-Delivered Meals

Unsure

No Meals-on-Wheels Services Needed

Are you physically able to safely prepare healthy meals by yourself?*

Yes

Are you able to drive your own car, walk, or use public transportation safely by yourself to get to the places you need go?*

Yes

Based on this brief assessment, home-delivered meals may not the best LifeCare Alliance Nutrition Service for your situation. However, we have many other services that might be appropriate. A representative of the LifeCare Alliance will be calling to discuss more.

Based on this brief assessment it is likely that you or your loved one would benefit from LifeCare Alliance’s home-delivered meals program.

If you would like to save time, please complete the following questionnaire with the appropriate responses for yourself or the applicant. Otherwise, a LifeCare Alliance representative will call you during regular business hours to complete the application over the phone. IMPORTANT NOTE: if you are filling out this questionnaire on behalf of someone else, LifeCare Alliance expects that you have confirmed with your loved one that he/she wants to receive the home-delivered meal service and is aware that it will be starting in the near future.

Demographic Questions - Meals on Wheels

Last 4 of SSN

Gender Identity

Male

Female

Other

Marital Status

Divorced

Single

Married

Separated

Widowed

Are you a veteran

Yes

Do you have your DD214?

Yes

Are you a spouse of a veteran?

Yes

Race

Asian / Pacific Islander

Black

Hispanic

Native American

White

Two or more races

Others

Ethnicity

Hispanic

Non Hispanic

HouseHold Composition

Lives Alone

Lives with spouse

Lives with Other Family

Lives with Roommate

Number of People living in the Household

Please enter a number from 0 to 50.

Do you rent or own your home?

Rent

Own Home

Do you have pets

Dogs

Cats

Others

Approximate Monthly Income

Please enter a number from 0 to 50000.

Emergency Contacts

Name: 1

First Last

Name: 2

First Last

Phone: 1

Phone: 2

Email: 1

Email: 2

Relationship: 1

Relationship: 2

Once you have completed this home-delivered meals questionnaire, you will be taken back to the LifeCare Alliance general referral form.

Medical & Safety Questions

Do you use any of the following mobility devices?

Walker

Cane

Wheelchair

None

Do you have a fear of falling?

Yes

Are you ever unsteady when walking?

Yes

Sometimes

Have you gone to the ER or hospital, and/or have you had a nursing home placement in the last 30 days? (check all that apply)

Hospital

Nursing Home

Are you Diabetic

Yes

Do you have arthritis?

Yes

Have you experienced any of the following cardiac conditions? (check all that apply)

High blood pressure or hypertension

Heart attack

Congestive heart failure

Coronary artery disease

Stroke

Other

Other, Please provide details:

Please list any other medical conditions you currently are experiencing that LifeCare Alliance should be aware of (i.e. COPD, memory issues, vision / hearing impairment, kidney disease, etc).

How confident are you that you have the support systems in place to remain safely at home? (“Support systems” can be whatever you believe this to mean.) (1 – not confident; 5 – very confident)

Once you have completed this home-delivered meals questionnaire, you will be taken back to the LifeCare Alliance general referral form.

Meals on Wheels - Meal Service Preferences

What date would you like to start your meals?

As soon as possible

On this Specific date

On this Specific Date

MM slash DD slash YYYY

What type of meal delivery is best for you? (select your preference – you must be home at time of delivery. Meals cannot be left at the door or with a neighbor.)

Daily delivery (deliveries are hot or cold and are made typically between 10:00 and 2:00)

What days of the week do you want deliveries? (select all that apply)

It is possible you will qualify to receive enhanced meal services that include a hot and a cold meal delivery each day and/or deliveries on the weekends. One of the LifeCare Alliance case managers will make this determination based on your unique situation.

Weekly delivery (deliveries are frozen and only come once a week on a set day between 8:00 and 4:00)

Are there any days of the week that cannot work for you to receive your frozen meal delivery?

Yes

If yes, please tell us which day(s) of the week do not work for you to receive your delivery.

It is possible you will qualify to receive up to 14 meals per week with your delivery. One of the LifeCare Alliance case managers will make this determination based on your unique situation.

What meal type would you like to receive? (select one)

Daily hot homestyle (meatloaf, spaghetti & meatballs, country fried steak)

Daily cold delistyle (salads, cold sandwiches, pasta salads)

Daily vegetarian (veggie burger, pasta)

Daily mechanical soft (for those with cutting or chewing issues)

Daily hot or chilled puree (for those requiring a liquid diet)

Daily kosher

Weekly frozen (follows the hot homestyle menu)

Weekly vegetarian (follows the hot vegetarian menu)

Weekly puree (follows the hot puree menu)

Weekly kosher (follows the daily kosher menu)

What type of beverage would you like to receive? (select one)

Orange juice

Milk

None

Do you have any dietary restrictions or allergies we should know about? LifeCare Alliance has a team of Registered Dietitians and a Dietetic Technician who is able to help you make sure you get the right meals for you, if you do.

Yes

If yes, please explain i.e. nut allergy, renal failure, gluten intolerance, etc.

Please provide any delivery instructions that will help our drivers make a safe and successful delivery. (i.e. hard of hearing, use back door, doorbell doesn’t work – knock hard, call before arriving so dog can be put away, etc)

The signature or initials of the person receiving the meal(s) is required at each delivery. If there is any issue with this, please explain below. (Meals cannot be left unattended.)

LifeCare Alliance’s home-delivered meals are provided at no cost to its customers. However, we appreciate and accept contributions to the program. Even .10 per meal (approximately $2.50 per month) can help LifeCare Alliance sustain the service for all in need. If you are interested in contributing towards the cost of your meal, please indicate the amount per meal that would be comfortable for you. LifeCare Alliance will send you monthly reminder letters to indicate how much you have pledged to contribute towards your meals. Contributing the amount in the “pledge” letter is not mandatory to continue to receive the service. Additionally, your pledged amount per meal can be lowered, raised, or discontinued at any time. As mentioned above, there is no cost for the meals, and service will not be denied if you are unable to contribute towards the program. We are honored to serve our customers regardless!

Contribution

I pledge ______________ per LifeCare Alliance home-delivered meal I receive.

I am not able to contribute at this time.

I pledge ______________ per LifeCare Alliance home-delivered meal I receive.

Before we return to full LifeCare Alliance referral, please share any additional information about why this person may need Meals on Wheels and anything else that would help our team better support them. You will also have the opportunity to select other support services after this form is complete. Additionally, please share any information about the best way to contact the meal recipient to complete the enrollment process

Once you have completed this home-delivered meals questionnaire, you will be taken back to the LifeCare Alliance general referral form.

Services Being Requested

Which LifeCare Alliance services are you seeking?

Senior Dining Centers

Senior Dining Centers provide meals for older adults at senior community dining centers and restaurants in over 40 locations across central Ohio. LifeCare Alliance’s dining centers offer socialization, enriching programming and a nutritious meal.

Senior Dining Centers

Transportation to Senior Dining Centers

Unsure

No Senior Dining Center Services Needed

This field is hidden when viewing the form

AEP Food Replacement Program

This program is for residents of central Ohio adversely effected by the electric power outages of June 13-17, 2022. Please specify if this is a food replacement request or inquiry regarding other assistance related to the outage. LifeCare Alliance is not providing store gift cards at this time as a part of the AEP Food Replacement Program. For information on agencies that may have funding available for gift cards, please visit the AEP website’s “Neighbor to Neighbor Program” page.

Food Replacement

Help-at-Home

Help-at-Home provides direct care and personal care assistance with activities of daily living, such as bathing, fall prevention, meal preparation, errands and basic household chores to help individuals live comfortably and independently in their homes longer. The program serves clients in Franklin and Madison Counties.

Help-at-Home

Unsure

No Help-at-Home Services Needed

Wellness Services

Specialized wellness assistance for older adults aged 60+ throughout Franklin County. LifeCare Alliance’s registered nurses and registered dietitians have expertise in foot care, health assessments, and disease prevention and management.

Senior Foot Care

Diabetic Counseling

Year-round Diabetes Education Programs

Unsure

No Wellness Services Needed

Columbus Cancer Clinic

The Columbus Cancer Clinic provides low-cost or free cancer screenings and mammograms.

Cancer Screening or Mammogram

Unsure

No Columbus Cancer Clinic Services Needed

HIV/AIDS Nutritional Support Services

Our HIV/AIDS Nutritional Support Services provides home-delivered, as well as nutrition counseling to individuals living with HIV/AIDS in Central Ohio.

HIV/AIDS Nutritional Support Services

Unsure

No HIV/AIDS Nutritional Support Services

Home Repair Services

Home repair assistance for clients in need of safety and health related maintenance.

Home Repair

Unsure

No Home Repair Services Needed

Travel Vaccinations

Travel Vaccinations Needed

No Travel Vaccinations Needed

Other/I Don't Know

Please describe your referral request below.

Demographics

Race*

Gender*

Household Size*

Ages of Household Member(s)*

Please list the age of each household member. Please do not include household member names.

Requested Services

Meal Type*

10 Frozen Meals (home-style frozen meals in 3-compartment trays)

2 Carrie’s Café Cold Meals (deli-style boxed lunches)

Number of 10-packs of frozen meals requested per week*

Limited to the number of individuals in the household, and to your available storage space.

Number of weeks you would like to receive the meals*

Subject to funding availability.

Please enter a number from 1 to 10.

Number of 2-packs of Carrie's Café cold meals requested per week*

Limited to the number of individuals in the household, and to your available storage space.

Number of weeks you would like to receive the meals*

Subject to funding availability.

Please enter a number from 1 to 10.

Pickup Day*

All frozen and cold meals will be available for pickup at Carrie’s Café, 670 Harmon Ave., 43223 between 11:00AM and 1:00PM.

Disclaimer

Release of Information*

LifeCare Alliance’s funding sources and community partners monitor the effectiveness of programs offered to its consumers. Therefore, it may be necessary for LifeCare Alliance to provide written or verbal health related and financial information for the purpose of providing and coordinating services received from the Agency. All information will be kept confidential and no personal identifying information will be released to the public without written consent, unless required under Federal law. Although all persons receiving services are asked to provide this information, no person may be denied services for refusing to provide any of the requested information. By submitting this completed online referral form to LifeCare Alliance, I agree that I have read the Release of Information statement and understand that my submitted information may be reported, as needed, to LifeCare Alliance’s funding sources and community partners.

I agree

Diabetic Counseling

Please Choose from the Services Below:

Individual counseling (in-home or office consulation)

Group counseling/classes

Both

I don't know

Diabetes Diagnosis Code*

A1C*

Columbus Cancer Clinic

Free or Low-Cost Cancer Screenings and Mammograms*

Mammograms, breast ultrasounds & breast biopsies

Pap tests and pelvic exams

Colon cancer screening tests

Prostate cancer screening tests

Skin cancer screening tests

When was the patient's last mammogram?*

Where was the patient's last mammogram performed?*

Are there any signs or symptoms such as a breast lump, nipple discharge or retraction, or breast dimpling?*

Please fax an order with diagnosis code to 614-263-5019.

Primary Care Provider Name

First Last

Primary Care Provider Address

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

Primary Care Provider Phone

Are Interpreter Services Needed?*

Yes

Unknown

Language Needed*

HIV/AIDS Nutritional Support Services

Year Tested Positive*

Check to Accept Statement*

HIV/AIDS nutritional support services serves clients with HIV/AIDS who are currently receiving treatment or seeking assistance for their status. Checking this box is a confirmation that the person in this referral is in active care with an HIV/AIDS provider.

Name of HIV Care Provider or Agency*

Do We Have Permission to Leave Voicemails Regarding POHC Information?

Yes

Unknown

Is this client enrolled in Ryan White Part A services?

Yes

Unknown

Is this client currently enrolled in the Eddie Hamilton Walmart Program?

Yes, they also need home delivered meals.

No, but I am sending a referral for that too ( Note: this program has its own special intake website.)

No, please share more information.

Program Options*

Home Delivered Meals (home delivered meals or frozen meals picked up from our office for food insecure individuals or those that cannot prepare meals for them)

General dietetic counseling

Diabetes counseling

Unsure

Home Delivered Meals

Select delivery method below:

Delivery

Pick-Up

Date of Delivery Start

We will do our best to deliver within 48 hours of the request.

MM slash DD slash YYYY

Meals will need to be picked up from 670 Harmon Ave between 9am-4pm. Please select your preferred pick up day:

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Reason for Request*

Does the Patient Live Alone?*

Yes

Unknown

Marital Status*

Married

Widowed

Single

Divorced

Unknown

Race*

Black

White

Hispanic

Asian

Indian

Other

Unknown

Ethnicity*

Hispanic

Not Hispanic

Unknown

Describe Dietetic Assistance Needed:*

Diabetes Counseling Type Requested:

Individual counseling (in-home or office consultation)

Group counseling/classes

Both

I don't know

Diabetes Diagnosis Code*

A1C*

Home Repair Services

Services provided according to funder requirements. Eligibility is not guaranteed. For more information, contact Customer Service at 614-278-3130.

Is the Person Being Referred a Homeowner?*

Yes

Unsure

Is the Person Being Referred a Resident of Franklin County, Ohio?*

Yes

Unsure

Is the Person Being Referred a Veteran, Spouse of a Veteran, or Surviving Spouse of a Veteran?*

Yes

Unsure

Is the Person Being Referred Over the Age of 60?*

Yes

Unsure

Brief Description of Repair Needed*

Referring Physician Information

Practice Name*

Phone*

Fax*

Address*

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

PCP/Referring Physician Name*

NPI #*

Medicare #*

Referring Agency Information

Name of Referring Agency*

Name of Agency Representative Making Referral*

Relationship to Patient*

Agency/Representative Phone*

Agency/Representative Email*

I have communicated the service basics and referral process for the identified LifeCare Alliance services to the person being referred.*

Yes

The patient referenced on this form agrees to proceed with the assessment process for the identified service(s).*

Yes

If you answered no above, provide background information so that we may proceed with initiating service.*

Family Referral Information

Name of Person Submitting this Form*

First Last

Relationship to Client*

Submit

How Did You Hear of LifeCare Alliance?

Your referral submission is almost complete. Please follow any instructions in the reCAPTCHA field below, then click Submit. If you have any questions or concerns about this process, please contact our Customer Service Department at 614-278-3130.

By submitting this form, I hereby consent to the disclosure of the records to the purpose and extent stated. This authorization may be revoked by the client at any time to the extent that disclosure has not already occurred prior to the request for revocation. I understand that in order to revoke this authorization I must do so in writing. I understand that the information used or disclosed as a result of this authorization may be subject to re-disclosure by the person or entity receiving such information.

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