Smiles Like Yours Service Application

Your First Name: *

Your Last Name: *

Your Phone #: *

Your Email: *

WAMS ID *

What services are you interested in? *

Group Day

Community Engagement

Community Coaching

Residential Living

Service Plan Start Date

Service Plan End Date

First Quarter Date

Second Quarter Date

Third Quarter Date

Fourth Quarter Date

Enter Individuals Diagnosis Code*

Level

1
2
3
4
5
6
7
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Tier

1
2
3
4
New to waiver program
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Does the individual display physical aggression towards others?

Yes

No

Behavioral Functioning

What supports are needed for this individual?

Legal Representation

Is the individual their own legal guardian

Yes

No

Who is the individuals legal guardian?

Individual Relationship With Guardian

Legal Guardians Email Address

Legal Guardians Contact Number

Authorized Agent Name

Individual Relationship With Agent

Authorized Agent Email Address

Authorized Agent Contact Number

Who is the individuals Support Coordinator

Support Coordinator Contact number

Support Coordinator email Address

Name of other involved family and or friends

Name of the person who will be responsible for paying the members monthly activity fee

The email address of the person responsible paying members monthly activity fee

Residential provider name

Residential Provider Email address

Residential Provider Phone number

Emergency Medical Information

Person to contact in case of an emergency

Person Relationship

Emergency Contact Phone Number

Enter Zip Code

Enter City

Enter State

Emergency Contact Address

Physicians Information

Current Physician

Physician Contact Number

Physician Address

Current Dentist

Dentist Phone Number

Dentist Address

Fax Number

Current Psychiatrist

Psychiatrist Phone number

Psychiatrist Fax Number

Psychiatrist Address

Insurance Information

Name of Medical Insurance Company

Policy number

Medicaid/Medicare/Champus number

Any allergies to medicine or food? If yes, please identify (medications and food)

Any history of substance abuse If yes, please explain

Does individual have significant ambulatory or sensory problems? If Yes Please Explain

Does the client have significant communication problems? If Yes Please Explain

Advance Directive if one exists?

Please upload the following files and mark completed once attached in the portal. All information will be sent securely through a private portal.

Upload State ID

Upload Social Security Card

Medicaid Eligibility Letter

Upload Current ISP

Upload VIDES

Upload SIS Report

Current Risk Assessment

Upload Comprehensive Diagnostic Assessment (If Applicable)

Upload Psychological Evaluation (If applicable)

Upload Seizure plan (if applicable)

Upload Fall Risk plan (If applicable)

Upload Behavior Plan (If applicable)

Upload Nutritional Protocol (if applicable)

Upload Physician Medication Order (if applicable)

Upload All Documents Here