Care Provider USA
2305 N. Hayes
Fresno, CA 93723
Toll free 1-800-330-2533
(559) 277-1666
Fax (559) 277-2745

CARE HOME OWNERS MUST SUBMIT THEIR INFORMATION BEFORE WE WILL REFER CLIENTS TO YOU. PLEASE CALL US TO GET NAME FOR ID NUMBER BELOW. 

Todays Date__9-1-09______
 

Name/ID number____09010901________Pt.____Charlotte G. ___
 

Ph Home________________________________Ph Cell______________________

Relationship:  XDaughter  ___DTR IN Law  ___SELF  __SISTER

Present Care__Skilled Nursing in Texas___Dr. approves RCFE_____

What is care seeker looking for?      _____Lg Assist       __X__6 Bed

Sex_F  Age   _85   ambulatory No_____W/Chair _Yes___

Care Needs.  _Yes__Incontinent  _No___BathesSelf   __Yes__Dementia Stage_1__ NO_Diabetes_NO__Lifting   Needs_NO_Feeding   NO___Falls   ___Other_Macular Degeneration, stroke, weakness, one side.__Co-operative, Pleasant Personality_____

Height_5'4"   Weight___130 Lbs

Location: State_CA__  City_Santa Barbara Zip___Any___

Price Range__$4000 or less______ 

I agree with terms and conditions as stated below.

RCFE  will be eligible to receive Referrals from CPUSA for a period of 1 year.  Care Provider USA makes no guarantee of finding residents for RCFE's.  Care Provider USA will be paid _65______ % of the first month's resident fee within 5 working days of admission to a care Provider USA directory member's RCFE.  If Care Providers referred and admitted residents stay is less than 30 days, Care Providers USA's Referral fee is 20% of the daily directory members resident fee charged the admitted resident on a prorated daily basis.  Upon admission of a resident referred by care Provider USA by phone, fax, writing, or email, directory member will remit full payment as stated above and a copy of the admission agreement (if requested) to Care Provider USA.  Directory membership is non-transferable.  The Care Provider USA directory member agrees to pay all collection and court costs of any unpaid or past due fee owed Care Provider USA.  A late penalty of 10% per resident daily fee will be added to accounts not paid in full 30 days net.

E-mail Address: * Todays Date * Time: * City: * State: * Home Phone * Cell Phone: Fax: * Email Address * I accept the terms of this referral agreement. * Dont Leave Blank Verification Code: Enter Verification Code: * * Required

v