Optimum Health Care Host Home Application Optimum Health Care Host Home Application Home Optimum Health Care Host Home Application Instructions To ensure timely processing and help us match you with an appropriate client, please complete all questions, including the table of potential client needs. Incomplete applications will not be considered. When completed, email this application and a resume to hosthome@optimumhealthcareservicesllc.com. Thank you — we look forward to learning more about you. Applicant Information & Contact Details Date: First Name Last Name Street: City: State: ZIP: County: Phone: Email: 1. How did you hear about Optimum Healthcare Services LLC? 2. Do you currently or have you worked at Optimum Healthcare Services LLC? YesNo If yes, what dates? Primary Residence & Home Requirements Primary residence requirement: Host Home SCL delivery model is defined as a community-based family home setting whose owner or renter provides home and community-based services (HCBS) Waiver SCL services to no more than (2) individuals. The owner or renter must attest that the home they provide services in is their primary residence. 3. Is the home you will be providing support in your primary residence? YesNo 4. Are you willing to allow a thorough evaluation of your entire home? YesNo Minimum Eligibility Requirements 5. Working vehicle and valid auto insurance ($50/100/50K) YesNo 6. No more than three moving violations in 3 years; no major violations in 5 years YesNo 7. Ability to pass background/registry checks YesNo Professional Background & Experience 8. What do you currently do and what is your work experience? 9. Do you have disability-related experience? YesNo If yes, describe: 10. Have you provided mental health supports? YesNo If yes, describe: 11. Have you worked in Host Home Services? YesNo If yes, describe: 12. Have you ever been an Independent Contractor? YesNo If yes, describe: 13. Do you have healthcare-related certifications or training? YesNo If yes, describe: Home & Household Environment 14. Tell us about your home and household members: 15. Do you have pets? YesNo 16. Would you accept a client with a pet? YesNo If yes, restrictions: 17. Do you have stairs? YesNo If yes, describe: 18. How many rooms are available to the client? 19. Are there restricted areas in your home? YesNo If yes, specify: 20. Does anyone in the house smoke? YesNo Work Preferences & Lifestyle Considerations 21. Will this be your only job? YesNo 22. If not, how many hours do you plan to work? 23. Notice period for leaving job: 24. Is this short-term or permanent? Short termPermanent Details: Financial Expectations 25. Required salary range: 26. Rent you would charge: Skills & Technology Competencies 27. Technological skills: 28. EHR systems used: Motivation & Fit 29. Questions for us: Client Compatibility & Support Capabilities 30. Comfortable supporting religious activities? YesNo 31. Any food restrictions you cannot assist with? YesNo If yes: 32. Preferred client gender: MaleFemaleNo Preference 33. Other client characteristics: Client Specific Needs Please indicate your ability to meet the following needs: Client Specific Needs Response Comment Transportation - regular vehicle YesNoMaybe Wheelchair Accessible - vehicle YesNoMaybe Wheelchair Accessible - home YesNoMaybe Ramp YesNoMaybe Zero grade shower YesNoMaybe Room for shower chair YesNoMaybe Wide hallways / doors YesNoMaybe Personal Care YesNoMaybe Physical Transfer YesNoMaybe Behavior Support YesNoMaybe Hitting YesNoMaybe Self-harm YesNoMaybe Eloping YesNoMaybe Suicidal ideation YesNoMaybe Seizure Disorder YesNoMaybe Diabetes YesNoMaybe Medication Management YesNoMaybe Hearing Impaired YesNoMaybe Visual Impairment YesNoMaybe Justice Involved YesNoMaybe Substance Abuse (Active) YesNoMaybe Substance Recovery YesNoMaybe Resume Upload: Thank you for completing the Optimum Healthcare Services LLC Host Home Provider application. We will review your submission and contact you soon.
