• Elder Care Program

  • Application for 90 Day, Medical/Dental

    (Must be 55 or older and an active client)
  • Applicant Information

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  • Medical Assistance

    One (1) request per assistance, up to $200 on current amount Must provide current RX & Invoice for all medical assistance. ***No cosmetic procedure paid for on Medical/Dental***
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  • ***Elder Care Program does not reimburse any services provided***

  • AUTHORIZATION FOR RELEASE OF INFORMATION

  • I hereby authorize you to release any information from any medical facility, institutions, the Social Security Administration, any local, State, or Federal Law Enforcement Agency, or any other agency. I understand that his information is to be held confidential by all parties.

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  • The information is to be released from:

  • This authorization will terminate one year from the date of my signature. It is further understood that I may revoke this authorization any time by written request except to the extent that action has been taken in reliance theron.

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  • Clear
  • Should be Empty: