Home Health Care HHC Application and Requirement - CINICO - cinico 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the MEMBER INFORMATION section. Enter your last name, first name, middle name, street address, district, P.O. Box number, gender, birth date, home telephone, work telephone, and cell phone.
3. Select whether you are employing a care provider directly or using a home health care vendor. If employing directly, complete the care provider's information including their last name, first name, street address, gender, birth date, and contact details.
4. If using a home health care vendor, provide the company name and complete the vendor's representative information similarly as above.
5. Review all entered information for accuracy. Ensure that you certify the truthfulness of your application by signing and dating the form at the bottom.

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