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Invoice
Services
Long Term Care Services
Services for under 21 y/o
Medicaid Waiver Services
Insurance Accepted
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Community Inclusion
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Covid 19
Health Summary
Home
About
Our Vision & Values
Our Mission
Meet our Team
Message from the Administrator
Need Our Services?
Invoice
Services
Long Term Care Services
Services for under 21 y/o
Medicaid Waiver Services
Insurance Accepted
Resources
Community Inclusion
Continue Education
Covid 19
Health Summary
Client Name
*
First Name
Last Name
Date of Birth
*
MM
DD
YYYY
Parent/ Legal Guardian
*
First Name
Last Name
Address
*
Address 1
Address 2
*
City, State, Zip Code
County
*
Select one:
Orange
Osceola
Seminole
Brevard
Polk
Phone
*
(###)
###
####
Email
*
Medicaid ID Number
Which insurance do you have?
*
Select One
LTC
Simply Health Care
Sunshine Health
Wellcare
Staywell
Children Medical Services (CMS)
Medicaid Waiver Services
None
Do you send and receive text messages?
*
Select one
Yes
No
Please tell us which days and times are you requesting services?
example: monday-friday 2pm-5pm saturdays 1pm-6pm
Services Needed (Check all that apply)
*
Personal Care Services
Respite Care Services
Personal Supports
Life Skills Development Level 1
Diagnosis
*
Autism
Cerebral Palsy
Intellectual Disability
Prader-illi Syndrome
Spina Bifida
Down syndrome
Other
Thank you, we will get in contact with you within 24 business hrs.
