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Partners in Care
Home Care

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Potential Client Information

Please inform us of your current diagnosis(s)

Are you currently receiving services?

Yes

No

Do you have any of the following waivers? * Required

Aging Waiver

COMMCARE Waiver

Independence Waiver

OBRA Waiver

Attendant Care Waiver

ACT 150 Program

Community Health Choices (CHC)

Private Pay

None of these

How many hours do you need assistance per week?

What Services Do You Need? * Required

Bathing

Dressing

Toileting

Shaving

Hair, Nail, Skin Care

Laundry

Light House Keeping

Transportation

Transfer/ Ambulation

Medical Reminder

Meal Prep. / Cooking

Feeding

Request Custom Service

Do you have any of the following Health Care Providers? * Required

AmeriHealth Caritas of PA

Centene PA Health Wellness

Keystone First Community Health Choices

UPMC Health Plan

None of these

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