Forms – Podiatry/Ear Care

Ear Care/Audiology

Ear Care Consent Form
This form is required for a resident to be seen by the ear care specialist for a free ear care screening procedure.

Ear Care Fee for Service Consent
This form is used by a resident or his/her power of attorney/guardian for ear care services based on a fee for service schedule. This usually pertains to private pay residents who are not eligible for the Medicaid Special Care Insurance Program. A signature is required on this form.

Podiatry

Podiatry Services Authorization Form
This form requires a signature by a resident or his/her power of attorney/guardian to authorize consent to be seen by a podiatrist.

Podiatry Fee for Service Consent
This form is used by a resident or his/her power of attorney/guardian for podiatry services based on a fee for service schedule. This usually pertains to private pay residents who are not eligible for the Medicaid Special Care Insurance Program. A signature is required on this form.

Misc.

Change Form 2015
This Change form is filled out by your facility to notify SCS of a resident’s change in the program. (Transfers, expirations, family chooses to terminate the policy.)