When you are seeking medical care for an older adult, you may need to contact multiple agencies and offices before you get the information you need. This document contains a form to use when contacting these organizations so that you can keep track of your conversations and record the information for future reference.
Make several copies of the caregiver's contact form (see below). This contact form will help you organize the information you need and will serve as a reminder of the questions you should ask.
Credit: Ciaran Griffin
Here is a sample outline to follow for the contact:
My name is: _____________________________________________________________
Who am I speaking to? __________________________________________________
I'm caring for: ____________________________________________________________
I need: __________________________________________________________________
Can you help me? ____Yes ____No
If "No": Can you refer me to anyone else? _______________________________________
How can I contact them? ____________________________________________________
If "Yes," continue with the following questions:
What services do you provide? _____________________________________________
______________________________________________________________________
What are the costs? ______________________________________________________
How are they paid? ______________________________________________________
_____________________________________________________________________
What are the eligibility requirements?
____________________________________________________________________
Is there a wait for services? If yes, how long must we wait? __________________________________________________
Will you send me a brochure or application? __________________________________
Is there anyone else I should speak to?
______________________________________________________________________
When can I expect to hear from you? _________________________________________
Thank you for your help.
Complete this section immediately after the contact.
Agency contacted: _______________________________________________________
Specific doctor or professional contacted: _____________________________________
Method of contact: _______________________________________________________
Phone number: __________________________________________________________
Email address: __________________________________________________________
Mailing address: _________________________________________________________
Date of contact: __________________________________________________________
For More Information
This is one of six publications in a series on caregiving and aging. The other publications in this series are:
FCS2257: Long-Term Care: Places to Call Home (https://edis.ifas.ufl.edu/fy869)
FCS2259: Puzzled by Your Care Receiver's Refusal of Services? (https://edis.ifas.ufl.edu/fy871)
FCS2260: Balancing Work and Caregiving: Tips for Employees (https://edis.ifas.ufl.edu/fy872)
FCS2261: Balancing Work and Caregiving: A Guide for Employers (https://edis.ifas.ufl.edu/fy873)
FCS2262: Final Wishes: End-of-Life Decisions (https://edis.ifas.ufl.edu/fy874)