(504) 835-0006
Call us TOLL FREE at (833) 726-3466 for more information or visit
ccano.org/pace
Menu
Home
About
Who We Are
What We Do
Our Family
Participants
Caregivers
Answers
News & Events
News
Events
Contact
Enrollment Form
Close Menu
PACE Surprise Birthday Visit
September 24, 2020
@
1:50 pm
–
December 31, 2020
@
12:00 am
Pace Qualification Form
In order to qualify for PACE’s Healthcare & Caregiver services, you must meet the eligibility requirements included in this form. Please complete this form to determine if you are eligible for PACE. If you have any questions, please contact our intake enrollment number at 504-835-0006.
Step 1 of 3
33%
Do you have a physical or mental health deficit that requires therapy, treatment or daily assistance?
*
Yes
No
Unsure
Is your monthly income less than $2349 a month?
*
Yes
No
Unsure
Are you willing to change your health insurance?
*
Yes
No
Unsure
Which Zip Code do you live in?
*
Full Name
*
Email
*
Phone
*
Birth Date
*
Address including Zip Code
*
Which service(s) were you interested in learning about?
*
Primary care and specialty medical care
Medication monitoring
Physical/Occupational/Speech therapy
Transportation (to and from medical appointments)
Personal care (dressing, bathing, grooming, toileting, feeding)
Adult day health center
Nutritional counseling
Social services
Social activities
How did you hear about PACE Greater New Orleans?
*
CAPTCHA
Name
This field is for validation purposes and should be left unchanged.
×