Step 1: Application
If you are interested in enrolling your loved one, please print the following documents, fill out, and bring in with you for intake.
Step 2 – Fill Out Doctor Information
These items will need to be filled out by your medical professional. Please print and take it to your primary physician.
Your loved one’s doctor should have in their file what is needed to complete the form. Complete personal information at top of the form.
A current TB clearance completed within the year must be provided.
This form takes the place of the Advance Directive or goes hand in hand with it. Family/caregiver should complete the form regarding your loved ones wishes; your loved one should sign their signature if able, or the person who has Power of Attorney should sign off. The form should then be given to the doctor with the Physicians Form mentioned, because the doctor also needs to sign off on the POLST.
When the forms are complete and you pick them up, please check each form to make sure they are complete and the doctor has signed off on each form before you leave the office. This prevents you from having to go back to the doctor’s office if they have missed something.
If you have opted to fill out physical versions of the enrollment application and emergency form, hold on to them and bring to intake.
Once the forms are complete and you have picked them up from the doctor, call MADCC at (808) 871-5804 to schedule the intake. Hold onto all the forms and bring them with you to scheduled intake. You can choose to have the doctor fax the forms to (808) 877-4082.
Step 3 – Intake Process
Our program coordinator will schedule to meet you along with one of our lead staff at the center your loved one will be attending to go over all the paperwork. We will have you complete a few more forms we provide at the intake. The process takes 1 to 1 1/2 hours. You can bring your loved one with you or come along, either way is fine. It is difficult to talk about a person in front of them so they are not part of the intake process; if you choose to bring your loved one we will have them join our clients in the social room to meet others and enjoy some activity while we do the intake. Once the intake is done, your loved one is able to start attending.
We look forward to meeting you and providing support in any way we can to help you and your loved one feel comfortable in this process.