(513) 587-4923
BridgeCare Home Services LLC & BridgeCare Transportation LLC
BridgeCare

Client Forms & Documents

Fill out forms online, download PDFs, or call us and we'll walk you through everything.

(513) 587-4923 [email protected]

Fill Out Online

Complete these forms directly on our secure website — no printing required. A PDF copy is available after submission.

New Client Intake Form

Begin the enrollment process — personal information, physician details, insurance, and service needs.

Home CareOpen Form

Client Assessment Form

Mobility, bathing, dressing, meal prep, medication management, safety, and fall-risk assessment.

Home CareOpen Form

Service Request Form

Request home care services, specify your schedule, and describe your care needs.

Home CareOpen Form

Transportation Request Form

Schedule non-emergency medical transportation, wheelchair rides, and medical appointment trips.

TransportationOpen Form

HIPAA Authorization Form

Authorize BridgeCare to share your health information with designated individuals or organizations.

HIPAAOpen Form

Consent to Services

Authorize BridgeCare to provide home care and/or transportation services.

ConsentOpen Form

Emergency Contact Form

Provide emergency contacts and medical information for your BridgeCare care file.

RequiredOpen Form

Complaint / Grievance Form

Submit a formal complaint or grievance regarding BridgeCare services.

GeneralOpen Form

Client Referral Form

Refer a client to BridgeCare home care or transportation services.

GeneralOpen Form

Client Rights & Responsibilities

Review and acknowledge your rights and responsibilities as a BridgeCare client.

RequiredOpen Form

Release of Information

Authorize BridgeCare to release your health information to a designated person or organization.

HIPAAOpen Form

Care Plan Review

Review and update your current care plan, goals, and caregiver instructions.

Home CareOpen Form

Document Upload

Securely upload insurance cards, physician orders, identification, and other required documents.

GeneralOpen Form
View all forms in the Client Portal

Print a Completed Copy

Fill out any form online, submit it, then use your browser's Print function (Ctrl+P / Cmd+P) to save or print a copy for your records.

Client Intake Form

Home Care
Open Form

Client Assessment Form

Home Care
Open Form

HIPAA Authorization Form

HIPAA
Open Form

Consent for Services

Consent
Open Form

Complaint / Grievance Form

General
Open Form

Client Referral Form

General
Open Form
After submitting any form online, use Ctrl+P (Windows) or Cmd+P (Mac) to print or save a PDF copy for your records.

Request by Phone or Email

Call or email us and we'll send these forms directly to you.

Service Agreement

Review and sign the BridgeCare service agreement outlining terms of care.

General
Request

Insurance Verification Form

Submit your insurance information for billing and coverage verification.

Billing
Request

Physician Order Form

Physician authorization for home care services.

Medical
Request

Plan of Care (POC)

Detailed plan of care developed with your physician and care coordinator.

Medical
Request

Advance Directive / Living Will

Document your healthcare wishes and end-of-life care preferences.

Legal
Request

Power of Attorney for Healthcare

Designate a healthcare decision-maker on your behalf.

Legal
Request

Medicaid / Medicare Enrollment

Assistance with Medicaid or Medicare enrollment paperwork.

Billing
Request

Need help with a form? Call us at (513) 587-4923, fax us at (283) 223-9812, or email [email protected]. You may also mail completed forms to P.O. Box 53002, Cincinnati, Ohio 45253. Our intake coordinators are available to walk you through the enrollment process and help you complete any required forms.

Prefer to Complete Forms by Phone?

Our intake coordinators can walk you through the enrollment process over the phone.

Call (513) 587-4923

Request Services Online

Fill out our online service request form and we'll send you the forms you need.

Request Services