Pillar Homecare
Client Inquiry Form
Please complete all of the required fields.
You will be contacted within 24 business hours of receipt.
Who are you requesting services for?
*
First Name
Last Name
Date of Birth for person requesting services
-
Month
-
Day
Year
Date
Best contact email
*
example@example.com
Best Contact Number
*
Please enter a valid phone number.
Best Contact Time
Morning
Afternoon
Evening
Who is interested in homecare services?
*
Myself
Loved One
How soon are services needed?
*
Within next 48 hours
Within next 2 weeks
Unsure
Has the individual received homecare services before?
*
Yes
No
Unsure
List the service address (the location where homecare services will be rendered- we sometimes are required to get approval based on zip code)
*
Do you have long term care insurance or workers comp?
Yes
No
Unsure
Do you have health insurance?
*
Medicare Advantage
Medicaid
No Insurance
I am interested in private pay
Other
Do you need information on applying for Medicaid Waiver?
*
Yes
No
Unsure
Insurance Carrier Name & Member ID
*
Upload the front pic of the insurance card
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Upload the back view of the insurance card
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Is individual who service is being requested for a Veteran or Surviving Spouse of a Veteran? If yes, have you requested information from VA service center on the Aid & Attendance benefit. If no, we can refer you to an agency that can assist with determining eligibility for this benefit, free of charge.
*
Yes, I have requested information from VA on Aid and Attendance Benefit
No, I have NOT requested information from VA on Aid and Attendance Benefit
Unsure
Preferred Times
8a-12p
10a-2p
12p-4p
2p-6p
other, list below
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
List other times, not listed above
Signature
*
Clear
Submit
Should be Empty: