Medicaid / Medicare

"*" indicates required fields

Client Contact Information

Name*
MM slash DD slash YYYY
Address*
MM slash DD slash YYYY
Does the Applicant have SSI Medicaid?*
Primary Contact Name
What kind of assistance are you or the client in need of?*
MM slash DD slash YYYY
Agency Contact Name
Was the client advised of referral?
Was cost share discussed?
Is Alzheimer's disease or cognitive impairment suspected or diagnosed?
Does the person needing services live alone?
Does the person needing services live in a rural area?
Has the person needing services had any falls within the last 6 months?
Has the person needing services had any Nursing Home/Rehab stays in the last 12 months?
Has the person needing services had any ER visits or hospital stays within the last 6 months?
Is the person needing services below the poverty level and/or receiving public assistance?
Food stamps/SNAP, TANF, LIHEAP, Medicaid, etc.
Does the person needing services require an English translator?
Is the person needing services an ethnic minority?
White/Caucasian select 'No,' everyone else is 'Yes.'
Does the person needing services need assistance with any of the following activities?

Family Care Incorporated

Headquarters: 519 Mt. Pleasant Rd., Thomson, GA 30824
Ancillary Office: 10A Simonton Bridge Rd. Watkinsville, GA, 30677
Ancillary Office: 2353 Wrightsboro Rd., Augusta, GA, 30904

(706)-597-1890

Office Hours

Monday - Friday: 8am - 5pm
Saturday: By appointment
Sunday: Closed