Pillar Homecare Client Inquiry Form

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 NameLast Name
Date of Birth for person requesting services

MonthDayYear
Date
Best contact email*
example@example.com
Best Contact Number*
Please enter a valid phone number.
Best Contact Time

MorningAfternoonEvening
Who is interested in homecare services?*

MyselfLoved One
How soon are services needed?*

Within next 48 hoursWithin next 2 weeksUnsure
Has the individual received homecare services before?*

YesNoUnsure
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?

YesNoUnsure
Do you have health insurance?*

Medicare AdvantageMedicaidNo InsuranceI am interested in private payOther
Do you need information on applying for Medicaid Waiver?*

YesNoUnsure
Insurance Carrier Name & Member ID*
Upload the front pic of the insurance card*

Cancelof
Upload the back view of the insurance card *

Cancelof
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 BenefitNo, I have NOT requested information from VA on Aid and Attendance BenefitUnsure
Preferred Times

8a-12p10a-2p12p-4p2p-6pother, list belowMondayTuesdayWednesdayThursdayFridaySaturdaySunday
List other times, not listed above
Signature*

Clear
Should be Empty:

Pillar Homecare

Please complete all of the required fields.