MyCeridian 2006 banner

 

:
LifeWorks Elder Care Provider Form

 

The fields marked with an * below are required fields and must be completed before you can submit this form. If you have any questions while completing this form you can contact us at Central.DB@Ceridian.com or call our Provider Line at 800 290-4311, extension 5862. Leave your name and phone number and someone will return your call.
 
* New Provider Information    Updated Provider Information
 
Provider Name *
Phone * ()-
Main Contact *
Address *
City *
State *
Zip *
Email Address *
General Provider Type *
Licensure * Licensed    Exempt
Director
Capacity
Hours of operation From: :  AM  PM
To:     :  AM  PM
 
Please check off any of the following that apply:
General Services
Area Agency on Aging
Elder Care Resources
Senior Citizen Housing 

Consumer Services
Consumer Protection Services 
Insurance Complaints 
Mental Health Complaints 
Nursing Home Complaints 
Patients Rights Assistance 
Other 

Financial Services
Bill Paying and Money Management 
Consumer Credit Counseling 
Insurance - Health Insurance 
Insurance - Long Term Care 
Insurance - All Other 
Medicaid Waiver Programs 
Medicare / Medigap 
Reverse Mortgage 
Utility Disconnection and Fuel Assistance 
Viatical Settlement 

Legal
American Bar Association
Disability Law Centers
Elder Law Attorney
Legal & AdvocacyOorganization

Mental Health
Adult Protective Services
Assessment - Geriatric
Case (Care) Management
Community Mental Health Centers
Crisis - Rape Crisis Center
Mental Health - General

Support Groups
Alzheimer's Disease Support Group
AMI Support Group
Arthritis / Osteoporosis Support Group
Bereavement / Grief Support Group
Cancer Support Group
Caregiver Support Group
Depression Support Group
Grandparents Raising Grandchildren Support Group
Hearing / Vision Impairment Support Group
Heart Disease / Stroke Support Group
Parkinson's Disease Support Group
Support Group - General

Transportation
Adaptive Transportation Services
Air / Medical Transport
Driver Safety Programs
Elderly Transport / Senior Shuttle
Paratransit / Ambulance Service
Public Transportation
Other Transportation

Health / Medical Facilities & Services
Adult Day Care Facilities
Assessment - Geriatric
Burn Care Centers
Cancer Care Centers
Dialysis Centers
Home and Workplace Modification
Home Health Agencies and Nursing Services
Home Medical Equipment
Homecare / Assistive Technology Manufacturers
Hospice Care
Hospital, Long-term
Hospital, Post-acute Rehabilitation
Infusion Therapy and Specialty Pharmacology
Nursing Homes, Skilled Nursing
Pain Management Programs
Pharmacy and Medical Supplies
Physical and Occupational Therapy
Physician / Dental Referral Lines
Prosthetics and Orthotics
Rehab Engineering Centers
Rehabilitation Facilities: Acute
Rehabilitation Facilities: Outpatient
Rehabilitation Facilities: Sub-acute
Transplant Programs: Bone Marrow
Transplant Programs: Organs
Other

Home & Community Services
Case (Care) Management
Companion / Sitter / Friendly Visitor Programs
Emergency Response
Homemaker / Housekeeping / Chore Services
Meal Programs
Recreational Programs
Senior Centers / Social Day Programs
Vocational Rehabilitation Programs
Volunteer Services

Housing Options
Assisted Living Facilities
Congregate Housing
Continuing Care Retirement Community
Home Sharing / Foster Care
Independent Retirement Community
Maintenance / Rehab / Repair
Subsidized Rental Housing

Information & Support Organizations
Alheimer's Association Chapters
Area Agency on Aging
Independent Living Centers
Local Organizations
National Organizations
State Organizations
United Way Chapters

 

 

 

Additional Information/Comments:
© 2008 Ceridian Corporation. All rights reserved.