Client Intake & Eligibility Form Checklist

Attendant details
Were the name and relationship of the PGA registered?
Were the date of birth for the PGA registered?
Were the contact information of the PGA noted down?
Audit verification
I acknowledge that I have read, understand and accept the information that has been shared with me the (Client) and/or the PGA during this intake and eligibility process.
Date of inspection
Time taken
Client signature
PGA signature if needed
Staff signature
Client details
Have you updated the client's full and legal name?
Have you updated the client's accurate and legal birthdate?
Have you updated the client's accurate and official social security number?
Have you updated the insurance provider's name and number?
Have you cross checked the client's age?
Have you updated the client's address?
Have you updated the client's telephone number?
Is the client qualified for services?
Were the names of the qualified person mentioned in the list?

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