Are you sure you want to exit? Your progress will be lost.
Who are you caring for?
Which best describes their mobility?
How well are they maintaining their hygiene?
How are they managing their medications?
Does their living environment pose any safety concerns?
Fall risks, spoiled food, or other threats to wellbeing
Are they experiencing any memory loss?
Which best describes your loved one's social life?
Acknowledgment of Disclosures and Authorization
By proceeding, I agree that I understand the following disclosures:
I. How We Work in Washington. Based on your preferences, we provide you with information about one or more of our contracted senior living providers ("Participating Communities") and provide your Senior Living Care Information to Participating Communities. The Participating Communities may contact you directly regarding their services. APFM does not endorse or recommend any provider. It is your sole responsibility to select the appropriate care for yourself or your loved one. We work with both you and the Participating Communities in your search. We do not permit our Advisors to have an ownership interest in Participating Communities.
II. How We Are Paid. We do not charge you any fee – we are paid by the Participating Communities. Some Participating Communities pay us a percentage of the first month's standard rate for the rent and care services you select. We invoice these fees after the senior moves in.
III. When We Tour. APFM tours certain Participating Communities in Washington (typically more in metropolitan areas than in rural areas.) During the 12 month period prior to December 31, 2017, we toured 86.2% of Participating Communities with capacity for 20 or more residents.
IV. No Obligation or Commitment. You have no obligation to use or to continue to use our services. Because you pay no fee to us, you will never need to ask for a refund.
V. Complaints. Please contact our Family Feedback Line at (866) 584-7340 or ConsumerFeedback@aplaceformom.com to report any complaint. Consumers have many avenues to address a dispute with any referral service company, including the right to file a complaint with the Attorney General's office at: Consumer Protection Division, 800 5th Avenue, Ste. 2000, Seattle, 98104 or 800-551-4636.
VI. No Waiver of Your Rights. APFM does not (and may not) require or even ask consumers seeking senior housing or care services in Washington State to sign waivers of liability for losses of personal property or injury or to sign waivers of any rights established under law.I agree that: A.I authorize A Place For Mom ("APFM") to collect certain personal and contact detail information, as well as relevant health care information about me or from me about the senior family member or relative I am assisting ("Senior Living Care Information"). B.APFM may provide information to me electronically. My electronic signature on agreements and documents has the same effect as if I signed them in ink. C.APFM may send all communications to me electronically via e-mail or by access to an APFM web site. D.If I want a paper copy, I can print a copy of the Disclosures or download the Disclosures for my records. E.This E-Sign Acknowledgement and Authorization applies to these Disclosures and all future Disclosures related to APFM's services, unless I revoke my authorization. You may revoke this authorization in writing at any time (except where we have already disclosed information before receiving your revocation.) This authorization will expire after one year. F.You consent to APFM's reaching out to you using a phone system than can auto-dial numbers (we miss rotary phones, too!), but this consent is not required to use our service.
✔
I acknowledge and authorize
✔
I consent to the collection of my consumer health data.*
✔
I consent to the sharing of my consumer health data with qualified home care agencies.*
*If I am consenting on behalf of someone else, I have the proper authorization to do so. By clicking Get My Results, you agree to our Privacy Policy. You also consent to receive calls and texts, which may be autodialed, from us and our customer communities. Your consent is not a condition to using our service. Please visit our Terms of Use. for information about our privacy practices.
Mostly Independent
Your loved one may not require home care or assisted living services at this time. However, continue to monitor their condition for changes and consider occasional in-home care services for help as needed.
Remember, this assessment is not a substitute for professional advice.
Share a few details and we will match you to trusted home care in your area:
Based on your profile, You live in Rhode Island, only 1 of 4 states that has temporary caregiver benefits. Please check the link below to check the portal for your state to see if you are eligible based on your state's requirements. http://www.dlt.ri.gov/tdi/ Temporary Caregiver Insurance (TCI) benefits are subject to Federal and State income taxes. If you receive TCI benefits, you will receive a General Form (G-1099) at the end of the year beginning in January 2015 indicating the amount you received in TCI benefits during 2014, which will also be reported to the IRS.
TDI provides benefit payments to insured RI workers for weeks of unemployment caused by a temporary disability or injury. The TDI program, enacted in 1942, was the first of its kind in the United States. It protects workers against wage loss resulting from a non-work related illness or injury, and is funded exclusively by Rhode Island workers. Only four other states; New York, New Jersey, California and Hawaii, as well as the commonwealth of Puerto Rico, have a TDI program. TDI customers can download the TDI/TCI application from our website.
Temporary Caregiver Insurance Program - The new Temporary Caregiver Insurance Program (TCI) was signed into law on July 11, 2013. TCI will provide eligible claimants up to four weeks of caregiver benefits to care for a seriously ill child, spouse, domestic partner, parent, parent-in-law or grandparent, or to bond with a newborn child, new adopted child or new foster-care child.
TCI claims will only be accepted as of January 5, 2014. You may file online or download a paper application; or you may call (401) 462-8420 and select option 1 for a paper application to be mailed to your home.
By proceeding, I agree that I understand the following disclosures:
I. How We Work in Washington.
Based on your preferences, we provide you with information about one or more of our contracted senior living providers ("Participating Communities") and provide your Senior Living Care Information to Participating Communities. The Participating Communities may contact you directly regarding their services.
APFM does not endorse or recommend any provider. It is your sole responsibility to select the appropriate care for yourself or your loved one. We work with both you and the Participating Communities in your search. We do not permit our Advisors to have an ownership interest in Participating Communities.
II. How We Are Paid.
We do not charge you any fee – we are paid by the Participating Communities. Some Participating Communities pay us a percentage of the first month's standard rate for the rent and care services you select. We invoice these fees after the senior moves in.
III. When We Tour.
APFM tours certain Participating Communities in Washington (typically more in metropolitan areas than in rural areas.) During the 12 month period prior to December 31, 2017, we toured 86.2% of Participating Communities with capacity for 20 or more residents.
IV. No Obligation or Commitment.
You have no obligation to use or to continue to use our services. Because you pay no fee to us, you will never need to ask for a refund.
V. Complaints.
Please contact our Family Feedback Line at (866) 584-7340 or ConsumerFeedback@aplaceformom.com to report any complaint. Consumers have many avenues to address a dispute with any referral service company, including the right to file a complaint with the Attorney General's office at: Consumer Protection Division, 800 5th Avenue, Ste. 2000, Seattle, 98104 or 800-551-4636.
VI. No Waiver of Your Rights.
APFM does not (and may not) require or even ask consumers seeking senior housing or care services in Washington State to sign waivers of liability for losses of personal property or injury or to sign waivers of any rights established under law.
I agree that:
A.
I authorize A Place For Mom ("APFM") to collect certain personal and contact detail information, as well as relevant health care information about me or from me about the senior family member or relative I am assisting ("Senior Living Care Information").
B.
APFM may provide information to me electronically. My electronic signature on agreements and documents has the same effect as if I signed them in ink.
C.
APFM may send all communications to me electronically via e-mail or by access to an APFM web site.
D.
If I want a paper copy, I can print a copy of the Disclosures or download the Disclosures for my records.
E.
This E-Sign Acknowledgement and Authorization applies to these Disclosures and all future Disclosures related to APFM's services, unless I revoke my authorization. You may revoke this authorization in writing at any time (except where we have already disclosed information before receiving your revocation.) This authorization will expire after one year.
F.
You consent to APFM's reaching out to you using a phone system than can auto-dial numbers (we miss rotary phones, too!), but this consent is not required to use our service.
http://www.dlt.ri.gov/tdi/
Temporary Caregiver Insurance (TCI) benefits are subject to Federal and State income taxes. If you receive TCI benefits, you will receive a General Form (G-1099) at the end of the year beginning in January 2015 indicating the amount you received in TCI benefits during 2014, which will also be reported to the IRS.
TDI provides benefit payments to insured RI workers for weeks of unemployment caused by a temporary disability or injury. The TDI program, enacted in 1942, was the first of its kind in the United States. It protects workers against wage loss resulting from a non-work related illness or injury, and is funded exclusively by Rhode Island workers. Only four other states; New York, New Jersey, California and Hawaii, as well as the commonwealth of Puerto Rico, have a TDI program.
TDI customers can download the TDI/TCI application from our website.
Temporary Caregiver Insurance Program -
The new Temporary Caregiver Insurance Program (TCI) was signed into law on July 11, 2013. TCI will provide eligible claimants up to four weeks of caregiver benefits to care for a seriously ill child, spouse, domestic partner, parent, parent-in-law or grandparent, or to bond with a newborn child, new adopted child or new foster-care child.
TCI claims will only be accepted as of January 5, 2014. You may file online or download a paper application; or you may call (401) 462-8420 and select option 1 for a paper application to be mailed to your home.
http://www.pace-ri.org/OurServices/CaregiverResources/tabid/252/Default.aspx