IHS Referral Form - Engage Community Services

Creating Pathways To A Better Way Of Life.

IHS Referrals

Referrals / IHS Referrals

Individualized Home Support (IHS) Form

If you would like to refer your client to ECS, please fill-out the form below or download a copy of our referral form and email the completed version to info@engagecommunityservices.com. We will reply, once your referral has been reviewed.

NPI #

Name

Date of Birth

Address

Phone

Social Security Number

PMI/MA#

Spend Down?

Yes No

If yes, has the client agreed to pay the Spend Down for IHS?

Yes No

Diagnosis

Physician's Name

Physician's Phone

Name of Clinic

Clinic Address

Social Worker/Case Manager

Phone

Is there a gender preference regarding the assigned staff?

No Male Female

Other information or concerns:

Emergency Contact Name

Phone

IHS Start Date

IHS End Date

Authorized IHS Hours Per Week

Supporting clients as they develop to their fullest potential, achieving the most comfortable lifestyle possible.

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Brooklyn Park, MN 55429

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612-261-7738

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info@engagecommunityservices.com

IHS Referrals

Individualized Home Support (IHS) Form

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