How to Complete the Home Help Services Agreement 📝

Hi there!

I'm Ansh, and I'm one of the owners at, Cova Home Care.

Today I'm going to be walking you through the Home Help Services Agreement.

And the purpose of this form is to let the state know that you and your patient will be joining through Cova Home Care as an agency provider.

So, to start, we're going to fill out Section 1, which includes the details of the patient themselves.

We're going to go ahead and write down the patient's name, their Medicaid ID number, the client's address, their date of birth, and then their city, state, and zip code, and then finally their phone number.

But you can also put your phone number here as the caregiver.

That's all there is to this side of the form.

Section 2 and 3 aren't for you to sign.

Then we go on to section four.

For section four, you have to have the patient go ahead and sign and date right at the bottom.

If you're the power of attorney or the legal guardian for the patient, you can also sign here instead.

The top line that I have crossed out over here is for the agency to sign.

So once you send an image of this form back to us, I will go ahead and sign, and date it accordingly.

Just a quick note.

Whenever you send images to our phone number, please make sure you don't cut out any of the image.

We want to see a clear, full scan of that image so it can help us when we fax it to the state.

That's all there is.

Really appreciate your time.

And as always, if you have any questions, don't hesitate to reach out to us.

Take care.

Bye.

Bye.