Aging and Disability Resource Center Intake/Screening Referral Form (PSA 5 - Area Agency on Aging of Pasco-Pinellas, Inc.)

Applicant Information (Individual for whom health care is needed)

* Applicant First Name

Applicant Middle Name

* Applicant Last Name

* Applicant Phone (Enter your number as contact person)

* Applicant Email (Enter your email as contact person)

* DOB

Age

* Social Security Number

* Gender

* Spoken Language

* Other Language

* Lives Alone

* Street Address

* State

* City

* Zip Code

* County

Contact Person Information (Individual who will be completing assesment on applicant's behalf)

Check if Contact person's information is same as Applicant information

* Contact First Name

Middle Name

* Contact Last Name

* Contact Phone

* Contact Email

* Relationship to Applicant

* Contact Person Street Address

* Contact Person State

* Contact Person City

* Contact Person Zip Code

* Contact Person County

Acknowledgement

Are you signing as the potential applicant? (Only click yes if you are the person who needs health care services – If you are a caregiver or other person completing this form for the person needing care you must answer “NO”)

Yes (I am the person needing health care) No (I am filling out this form for someone else who is needing care)

Are you the Health Care Surrogate?

Yes (I have been appointed by a legal document as the Health Care Surrogate / Power of Attorney for Health Care for the person needing care and am unrelated to the person needing care) No (I have not been legally appointed as a Health Care Surrogate / Power of Attorney for Health Care for the person needing care and am unrelated to the person needing care) No (I have not been legally appointed as a Health Care Surrogate / Power of Attorney for Health Care for the person needing care, but am related to the person needing care. Because I am related, no appoinment of a Health Care Surrogate is needed)

By checking here, I authorize Platinum to electronically sign the Release of Medical Information document on my behalf. (if you would like to view the authorization wording before providing such authorization click the “VIEW AUTHORIZATION” button.)

I, declare all provided information to be correct to the best of my knowledge and belief.

I understand and authorize my electronic signature to be placed on the appropriate form for the local Area Agency on Aging in the area the potential applicant for services lives.

Further, I authorize this form to be submitted to the local Area Agency on Aging for the potential applicant acting as a legal representative or family member.

I understand that I will be redirected to a payment page. The fee for the services Platinum will be providing is $4,695.00 and will be explained in detail on the payment page.

I UNDERSTAND I AM RESPONISBLE TO PROMPTLY NOTIFY PLATINUM WHEN THE POTENTIAL BENEFIT APPLICANT IS SELECTED FROM THE WAIT LIST BY CALLING 1-800-582-1934 EXT 208, OR PREFERABLY, BY EMAILING AND TYPING “SELECTED” TO WAITLIST@PLATBEN.COM, AND PROVIDING YOUR CONTACT INFO, I also understand that after being signed up for the assessment interview, receiving interview guidance via educational video, receiving one-on-one coaching (if desired) and confirming appropriate referral to CARES ONCE THE POTENTIAL APPLICANT IS SELECTED FROM THE LIST, any further services from Platinum will only occur if Platinum is hired to apply the applicant's for Medicaid benefits on applicant's behalf, I am fully aware that I am not required to hire Platinum or anyone else to submit my referral to the Area Agency on Aging OR to apply for Medicaid benefits and that I can do so myself at no charge. I attest that prior to being directed to this service, Platinum provided me a video explaining how to identify the appropriate ADRC and place the potential benefit applicant on the waitlist at no charge. If I choose to close my browser prior to submitting payment information, my information will not be saved, no charges will be incurred, and no referral will be made.

Make your payment

I understand that on behalf of myself or someone else, I am paying for a service that includes the provision of information about how to apply for an assessment regarding the need for Home Health Care or Assisted Living Care. Further, the service I am purchasing includes education about how the interview/assessment works, what to expect, and how to answer the questions honestly and as favorably as possible. The service further includes submitting information on my behalf (whether electronically or manually) and following up to confirm proper submission of information and follow through on the part of the agency responsible for the assessment and furtherance of the process. I understand that I am hiring Platinum for convenience of provided services and consolidation and provision of information. I understand that I am not required to hire Platinum to submit information to the Aging and Adult Resource Center (ADRC) in my area. I acknowledge that Platinum provided me information on how to contact the appropriate ADRC to place the potential benefit applicant on the Wait List without hiring Platinum or any other person or entity. I understand that the "Assessment Questionnaire" that the ADRC uses is publicly available and that purchasing Platinum's service and educational information does not guarantee that the potential benefit applicant will be selected from the Wait List more quickly, or at all. I understand that Platinum will make commercially reasonable efforts to provide quality service and results but does not guarantee results relating to selection from the Wait List. I further understand that I am purchasing the following:

Convenience – instead of having to identify the appropriate ADRC (Aging Disability Resource Center) for the area, 2) a)calling and sitting on hold b)playing phone tag to submit the name of the potential benefit applicant (or completing and properly submitting a form), 3) following up to make sure the screening call is actually scheduled 4) following up to confirm your loved one's "list ranking", and 5) following up to make sure the appropriate referral has been made to CARES (Comprehensive Assessment Review for Elderly Services) after the potential benefit applicant is selected from the Wait List - Platinum will do all of these items! Platinum does not however, conduct the assessment interview on the potential benefit applicant's behalf or the caregiver's behalf.
Education – Instead of "flying blind", we educate about how the system works via:
- Video - Explains what to expect during the assessment interview, what questions will be asked and why, how to honestly answer the questions while increasing the chances of a high "assessment score".
- Coaching call - Explains how to answer questions that were not answered on the video, if any.
Options - Once selected from the Wait List, what the options for filing the assistance application and also how to qualify financially for benefits are:
- We will conduct a fact-finding process to help you determine
- If assistance with the application process is needed because of excess assets, income, gifting, or other complications - we will be honest about what your options are and explain the pros and cons of each:
  - Do it yourself
  - ADRC
  - Attorney
  - Platinum and Attorney

I UNDERSTAND I AM RESPONISBLE TO PROMPTLY NOTIFY PLATINUM WHEN THE APPLICANT IS SELECTED FROM THE WAIT LIST! Any further services from Platinum will only occur if Platinum is hired to apply for Medicaid benefits on the person needing care's behalf. I am fully aware that I am not required to hire Platinum or anyone else to submit my referral to the Area Agency on Aging and that I can do so myself at no charge. I attest that prior to being directed to this service, Platinum provided me a video explaining how to identify the appropriate ADRC and place the potential benefit applicant on the waitlist at no charge. If I choose to close my browser prior to submitting payment information, my information will not be saved, no charges will be incurred, and no referral will be made.