Get On Behalf Of - Home Health Aide Request Form - Mass . Gov - Mass

This guide provides clear, step-by-step instructions on how to complete the ON BEHALF OF - HOME HEALTH AIDE REQUEST FORM. Designed for users seeking to screen prospective home health aides, this form may be submitted by legal guardians or individuals with power of attorney on behalf of an elderly or disabled person.

Follow the steps to successfully complete the home health aide request form.

1. Press the ‘Get Form’ button to access the form and open it in your chosen editing program.
2. In the 'Request Type Details' section, indicate the total number of subjects for whom you are requesting Criminal Offender Record Information (CORI). Ensure this number accurately reflects your submissions.
3. Complete the 'Requestor Details' section using the information of the individual submitting the request. Provide all required fields marked with a red asterisk, including first name, last name, date of birth, mailing address, and phone number.
4. Fill out the 'On Behalf Of' section with the details of the individual this request is being submitted for. Like the previous section, ensure that you complete all mandatory fields marked with an asterisk.
5. In the 'Subject Information' section, provide details for each subject whose CORI is being requested. Make copies of this section as necessary, ensuring each entry includes all required information such as first name, last name, date of birth, and the last six digits of the Social Security number.
6. Review the 'Elderly or Disabled Person's Agreement of Understanding' section carefully. The elderly or disabled person must acknowledge their understanding of the process and sign where indicated.
7. If required, complete the notary public section, ensuring it is signed and dated appropriately. This may involve confirming the identity of the signatory through satisfactory evidence.
8. Review the 'Terms and Conditions' carefully. Acknowledge your understanding of the responsibilities associated with the form, including compliance with applicable laws and guidelines.
9. Once all sections are completed, save your changes. You may download, print, or share the form as necessary. Ensure that the completed form is mailed to the address indicated at the top of the document.

Start filling out your request form online today!