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Provide Basic Information About the Person Seeking Care
Last Name:
*
First Name:
*
Date of Birth:
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November 2024
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Email:
Home Phone:
Cell Phone:
House Number:
Street:
Apt/Suite:
City:
State:
Zip Code:
County:
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Request Type:
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Preferred Contact Type:
*
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Requested By:
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Other Name:
Other Email:
Other Phone:
Description of Need:
Functional Needs Referral Information
Why does this person needs to be in the FNR?
Homebound/Service Auto Enrollment
Service:
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What is their disability?
Vision
Hearing
Mobility
Power Chair?
Yes
No
Walker?
Yes
No
Heart Disease
Diabetes
Seizures
Oxygen
Oxygen Machine?
Yes
No
Mental Health
Controlled by Meds?
Yes
No
Other
Describe:
Animals in the Home?
Yes
No
Service Animal?
Yes
No
Type:
Is English a second language?
Yes
No
Primary Language:
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Notes:
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Privacy Policy
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For the purpose of European Union Data Protection legislation, We (as defined and detailed in this website (our Site)) are the data controller.
Information we may collect from you
We may collect and process the following data about you:
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Information that you provide by filling in forms on our Site. This includes information provided at the time of registering to use our Site, subscribing to our service, posting material or requesting further services. We may also ask you for information when you enter a competition or promotion sponsored by us, and when you report a problem with our Site.
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If you contact us, we may keep a record of that correspondence.
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We may also ask you to complete surveys that we use for research purposes, although you do not have to respond to them.
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Details of transactions you carry out through our Site and of the fulfilment of your orders.
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Details of your visits to our Site including, but not limited to, traffic data, location data, weblogs and other communication data, whether this is required for our own billing purposes or otherwise and the resources that you access.
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