Medicaid Admission Packet | Bluelake Homecare

Client Identification

Personal details of the client receiving home care services

First Name * First name is required.

M.I.

Last Name * Last name is required.

Suffix

Date of Birth * Date of birth is required.

Gender *

Male Female

Please select gender.

Medical Record # (if known)

Anticipated Start of Care Date

Home Address * Home address is required.

City * City is required.

State * State is required.

ZIP * ZIP is required.

Phone * A reachable phone number is required.

Email * Valid email is required.

Living Situation

Lives With

Primary Caregiver

Emergency Contact

Name

Relationship

Phone

Evacuation Plan / Disaster Class

Advance Directive

Michigan's advance directive is the Patient Advocate Designation (also called a Durable Power of Attorney for Health Care), under MCL 700.5506. It must be signed in the presence of two qualified witnesses. If the client does not have one and would like information, the coordinator can refer them to a resource outside Bluelake Homecare.

Does the client have an Advance Directive?

Yes No

Location of Advance Directive (if Yes)

Clinical Assessment

Completed by the Bluelake Homecare care coordinator during the start-of-care visit

Household & Support

Marital Status

S M W D

Primary Language

Client/Caregiver Support

Good Fair Poor

Client Able to Receive Instructions

Yes No

Caregiver Limited By

Employment Physical Limitations Age Lack of Knowledge Other Responsibilities

General Information

Current Situation HX

Recent Hospitalizations

Height & Weight

Weight Status

Inc Static Dec

Recent WT Changes

Medications

Need for Palliative Care

Yes No

Dental Care

Vision

Hearing

Mental Health Status

Living Habits

Smoking - Client Smokes

Yes No

Smoking - Issue/Problem

Yes No

Alcohol - Client Drinks

Yes No

Alcohol - Issue/Problem

Yes No

Current Diet

Allergies / Food / Other

Communication Notes

Special Understanding

Activities of Daily Living (1 = Independent, A = Assistance Needed, U = Unable)

Activity	Level	Activity	Level

Instrumental Activities of Daily Living (iADLs)

Activity	Level	Activity	Level

Behavioral & Safety

Behavioral

Oriented Disoriented Agitated Anxious

Barriers

Safety Hazards

Other Issues

Home Situation Appropriate for Services

Yes No

If No, Explain

Assessing Care Coordinator

Assessor Name & Title

Assessment Date

Plan of Service / Care

Developed by the Bluelake Homecare RN/Supervisor and reviewed with the client

Identified Problems

Allergies

Diet

Functional Status

Assistive Devices

Psychosocial

Functional Limitations

Discipline(s) to Provide Care

Personal Care Worker Homemaker / Companion

Duration of Services

Frequency of Service

Hours of Service (AM/PM)

Special Requests from Client/Family

Supervisor / RN Name

Supervisor / RN Number

Frequency of Supervisory Visits

Goals

Insurance & 3rd Party Payer

Add up to three payer policies. Skip if billing is direct/private pay.

Service Authorization

Authorized services, charges, and financial responsibility

If your Bluelake Homecare admission coordinator pre-filled this packet for you, the service schedule and rates below will already be populated. Confirm or adjust as needed.

Payer Information

Will a 3rd Party Payer be billed?

Yes No

Expected Amount Payer Will Not Pay

Payer Pays

Your Portion

Hourly / Visit Rate

Out-of-Pocket Expense

Deductible

# of Covered Visits

Electronic Visit Verification (EVV)

Does a caregiver live with the client?

Yes No

Congregate living setting?

Yes No

EVV method (if EVV applies)

If using landline (IVR): I authorize the use of my landline telephone at the address above for electronic visit verification.

Authorized Services

Service	Charge	Frequency	Days	AM/PM
Personal Care Aide
Homemaker / Companion
Registered Nurse

Termination Notice (days)

When you're done with the staff sections above, save and generate a magic link to send to the client. The client will see your entries as read-only and complete the consent and signature sections.

Client Rights, Responsibilities & Grievance Policy

Click to open the full document. You must scroll to the bottom inside the document and tick the acceptance box before you can accept.

The full Client Rights, Responsibilities, and Grievance Policy opens in a separate document. You must read to the end before the Accept button enables.

✓ Rights and Policies acknowledged.

Consents & Authorizations

Required acknowledgments before Bluelake Homecare can provide and bill for services

HIPAA Notice of Privacy Practices

I acknowledge receipt of the HIPAA Notice of Privacy Practices.

Photo, Video & Recording Release

Yes, I authorize No, I do not authorize

Electronic Signature Consent

I authorize Bluelake Homecare to use my electronic signature for reimbursement of services.

Non-Discrimination & LEP Statement

I acknowledge receipt of the Non-Discrimination / LEP Statement.

Michigan Agency Status Disclosure

I acknowledge receipt of the Michigan Agency Status Disclosure.

Electronic Visit Verification (EVV) Notice

I acknowledge the Electronic Visit Verification notice.

Review of Admission Documents & Signature

Final acknowledgment that you have received the full Client Information Folder

This packet was completed by: *

Client Spouse Power of Attorney Family Member Other

Please select who completed this packet.

Relationship to Client (if not the client)

Print Full Legal Name * Print name is required.

Signature *

Date *

I have read this entire packet and consent to all terms, services, authorizations, and policies set forth above. My signature applies to all sections including the Client Rights and Responsibilities, Grievance Policy, HIPAA Notice, Photo/Video Release, Electronic Signature Consent, Non-Discrimination Statement, Michigan Agency Status Disclosure, Electronic Visit Verification Notice, and Review of Admission Documents.

You must open and accept the Rights and Policies above before submitting.

Admission Packet

Client link generated

Admission Packet Submitted

Submission Failed