(with Area IV Agency on Aging)

To refer a patient/client/yourself to the Area IV Agency on Aging programs (Medicaid Waiver, A&D or TBI; CHOICE; SSBG or TIII) the following information will aid you in the referral process.

This information is required by the State and the referral will not be done unless we have all the information. The process could take 1 hour or more.

Information Needed

• Patient’s Full Name
• Address and phone number
• Birth Date
• Social Security Number
• Medicaid Number (if applicable)
• Monthly Income
• Assets (bank accounts, 401K, stocks/bonds, trusts, CDs)
• Monthly Medical Expenses
• Cost of Medicare Part B and D
  • Do they receive Extra Help through Medicaid to pay for Parts B&D?
  • Cost of a Medigap policy
  • Monthly out of pocket expenses for prescription drugs
  • Monthly expenses for overdue medical bills
  • Monthly cost of Psychiatric Care
  • Monthly cost for private pay In-Home Services
  • Out of pocket costs for over the counter medications, supplements and incontinence products
• Medical Diagnosis and primary care physician name
• Date of most recent hospital or nursing facility stay
• Name, address and phone numbers for family member, caregiver, and/or emergency contact person – particularly if the referred has dementia/confusion
• ADL/IADL Functional Status (see attached sheet - coming soon)

Once we have this information we can then make an informed decision regarding program eligibility. The referred person and/or the caregiver/family member needs to be informed that they are being referred for in-home services and that they should contact us so that we may discuss the procedure with them. (Or that we will contact them – if you inform us that is what we need to do – in order to discuss the procedure.)

Most of the programs have a waiting list. The length of the time varies.

If you have any other questions, and/or wish to refer someone to our programs, please call our Link-Age Aged and Disabled Resource Center Helpline/Referral and Assistance program at 1-800-382-7556 or 765-447-7683.

Thank you,
Link-Age Aged and Disabled Resource Center
1-800-382-7556 or 1-765-447-7383

What Services Do You Need?

The following chart is designed to help you think about what services you may need. It asks you to consider the need for assistance with ordinary activities—shopping, bathing, paying bills, etc. Family and/or friends may be available to meet some of these needs. A paid home-care worker can do the rest.

Mark the ability level with the following code:

1. Can do this task
2. Can do this task with difficulty
3. Cannot do this task without assistance

Download a PDF version of the above chart. PDFs require Adobe Reader to Open/Read/Download.