Private Pay Case Management Referral Form
Get started with case management services from CICOA
Fill out this form to get started with case management services from CICOA Aging & In-Home Solutions.
We help older adults, people with disabilities, and family caregivers manage the services that help them live with independence, dignity and quality of life!
Private Pay Care Management Rate: $500/month
Our care management rate is competitive to provide you the best value with a personalized care plan to extend independent living.
Please note: This form is for individuals seeking private pay or self-pay services. If you would like to explore a Medicaid waiver or other public funding for case management, please contact our Aging & Disability Resource Center.
Case Management Referral Form
The referral form requests information that is privileged and confidential, including patient information protected by federal and state privacy laws. We use security measures on our website to protect against the loss, misuse and alteration of data used by our system. CICOA Aging & In-Home Solutions will not share, sell, rent or distribute personal information with anyone without your permission or unless ordered by a court of law. Information submitted to us is available only to employees managing this information for purposes of contacting you and assessing eligibility for services.