MIME-Version: 1.0 Content-Type: multipart/related; boundary="----=_NextPart_01C76BA1.28204A60" This document is a Single File Web Page, also known as a Web Archive file. If you are seeing this message, your browser or editor doesn't support Web Archive files. Please download a browser that supports Web Archive, such as Microsoft Internet Explorer. ------=_NextPart_01C76BA1.28204A60 Content-Location: file:///C:/9E74CAAD/NewApplicationForm.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" UPPER ARKANSAS AREA AGENCY ON AGING

UPPER = ARKANSAS AREA AGENCY ON AGING

 

APPLICATION= FORM

 

 

DATE:  _______________________________

 

NAME:  _______________________________    DATE OF BIRTH:  _______________

 

ADDRESS:  ____________________________ &= nbsp; CITY & ZIP:  ___________________

 

PHONE:  _= _____________________________

 

SERVICE(S) NEEDED:   (Please check)

 

Dental

 

 

Eyeglasses

 

Emergency

 

 

Homemaker

 

Personal Care

 

 

Chore/Home

 

Maintenance

 

 

Transportation

 

Caregiver Respite

 

 

Other (Please list below)

 

 

COMMENTS: (Please let us know of any emergency or extenuating circumstances.)

______________________________________________________= ___________________________________________________________________________= _______________

 

PLEASE ANSWER ALL QUESTIONS:

 

Do you have any insurance that covers all or part of t= he requested service(s)?  _______= _

 

Do you receive: =   Old Age Pension  _____<= span style=3D'mso-spacerun:yes'>         Medicare _____        =      Medicaid  _____    

 

   &nb= sp; Home & Community Based Services (HCBS)  _____     Home Care Allowa= nce  ____

 

   &nb= sp; Other Services (please identify)&nb= sp; __________________________________________

 

 

APPLICANT’S SIGNATURE  ___________________________DATE  ___________

 

**BELOW THIS LINE FOR = OFFICE USE ONLY**

 =

Application approved:&n= bsp; ______________________     Provider:  ____________________

Service  approved:  _________________________        =             &nb= sp; ____________________

Date: ____________________________________        =             &nb= sp; ____________________        =             &nb= sp;

 

q&nb= sp;      GENERAL FUNDS

q&nb= sp;      TITLE III FUNDS

q&nb= sp;      OTHER  ______________________

Comments:  ____________________________________________________________________= ___________________________________________________________________________= _________________________________________________________________________

------=_NextPart_01C76BA1.28204A60 Content-Location: file:///C:/9E74CAAD/NewApplicationForm_files/header.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii"

Phone:  719-539-3341        =   Address:   139 East 3rd Street, Salida, CO  81201=

Revised 02/06

------=_NextPart_01C76BA1.28204A60 Content-Location: file:///C:/9E74CAAD/NewApplicationForm_files/filelist.xml Content-Transfer-Encoding: quoted-printable Content-Type: text/xml; charset="utf-8" ------=_NextPart_01C76BA1.28204A60--