Client Application (PDF) Print & Fill Out
Client Application (Word) Download & Fill on Computer
You can choose to print PDF, or download Word doc and fill out online. If print, please sign and date with a black or blue pen. Then you can choose to either email it to hhhc.yingmandylin@gmail.com, or drop it off or mail it to our office. Feel free to stop by our office to fill out the applications. We are open Monday through Friday from 8 AM to 5 PM.
We require a copy of the patient’s valid driver’s license, social security card (signed) and insurance card. You can choose to take a picture and send to hhhc.yingmandylin@gmail.com, or make a copy and mail it to our office with the application, or we will make copies when you drop off the application at our office.
We also require a prescription or referral letter from your doctor indicate that you need personal care services, and they can fax the documents to us. Our fax number is (414) 461-2332.
What are the qualifications for personal care services?
The patient must be 11 years of age or older. Also, the patient must have a medical need and be functionally limited to provide care for yourself such as dressing, oral hygiene, hair care, bathroom assistant, bathing, light housekeeping, and cooking. the assessment nurse will contact the patient to schedule an assessment that will take approximately 1-2 hours.
Family Providing Care to Family Member
Anyone qualified to be a PCW can provide care for his/her family member if that family member agrees to it. However, you cannot be a parent, legal guardian, or have legal responsibilities for that family member. For example, a child 18 years or older can provide care for his/her mom, dad, sister, brother, aunt, uncles, or grandparents. A parent can be a PCW for a child over 18 but not a child who is a minor and is still legally under his/her care.
Personal Care Worker (PCW) Application
What kind of insurance does HHHC accept?
What’s the application process look like?
What services do we provide?