AFC CAREGIVER APPLICATION
By Email: info@unitedhomecarellc.com OR DROP IN THE MAIL TO THE ADDRESS LISTED
AFC Caregiver Paperwork Instructions
1. Application - You MUST fill out all information requested. All questions regarding the type of home and who lives there should be filled out based on the current home and family situation. For backup caregivers, just fill out the questions based on the home the person you will be caring for.
2. Background Check – The CORI Background Check must be completed in full, with all of your information. Send a clear, legible copy of your license as well.
3. Verification Documents - To qualify as a caregiver, you must provide documents to verify your identification and proof of address. Please see the checklist provided for all examples of documentation accepted.
Once you have completed all the requirements of the application packet, you can either give it to the Case Manager at the Orientation, mail or fax it to:
United Home Care LLC 360 W Boylston St., Ste. 209 Westboylston, MA 01583 Fax # 508-595-8993
*Once all the paperwork is received, an AFC staff member will call your references provided and send for your CORI, SORI, and OIG checks to be completed.
Please note, when emailing make sure to enter ENCRYPT: (the word encrypt with a colon after it) in the subject line before entering your subject. This will protect your personal information from hackers. Subject ENCRYPT:
ADULT FOSTER CARE CAREGIVER APPLICATION
Caregiver approval is subject to verification of your eligibility to work in the United States.
Please present to AFC staff a valid Driver’s License, Registration and proof of car insurance.
What was the date and position you applied for
Please provides program name and dates you were active
Is anyone in your home receiving Adult Foster Care, Shared Living, Personal Care Attendant, Hospice, Visiting Nurse, Homemaking, Elder Services or any other state funded, or MassHealth/ Medicare funded services
Please list all people who live in your home or who regularly spend time in your home
Educational History
WORK HISTORY- Please list your previous three employers starting with your most recent employer
REFERENCES
In order to be approved as a Caregiver in the Community Services Adult Foster Care program you must have a medical reference and two other references, either personal or professional. Your medical reference must come from a Primary Care Physician. Family members cannot be used as a reference.
OFFICE USE ONLY- DO NOT WRITE BELOW THIS LINE
CAREGIVER DOCUMENTS CHECKLIST Caregiver approval requires you present the following documents with your application to ensure it is processed in a timely manner. If the application is mailed or faxed in, please be prepared to display the documents to AFC staff at the home visit.
****For Primary Caregivers no documents will be accepted with an address other than the Qualified Setting****
Please note: the AFC Program does not collect copies or images of any required documents noted above. Please be prepared to show these documents to the AFC staff.
I consent to the collection, use, storage, and processing of my personal and, where applicable, health-related information, including any data I submit on behalf of others, for the purpose of evaluating or fulfilling my request made through this form. I understand this will be handled in accordance with the Privacy Notice.
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