Home Health Care is limited to Groups: 2026

1. Click ‘Get Form’ to open the Home Health Care application in the editor.
2. Begin by filling out the Member Information section. Enter the last name, first name, middle name, date of birth, gender, and contact details including email and phone numbers.
3. Choose either Section A or Section B based on whether a caregiver is employed directly or if you are contracting with an HHC agency. Fill in the relevant caregiver or agency details.
4. Complete the Patient’s Release section by providing your name and signature to authorize CINICO to release information regarding your application.
5. In the Declaration section, certify that all information provided is true and correct. If someone else is signing on behalf of the member, indicate their relationship.
6. Ensure all required documents from the checklist are attached before submitting your application electronically via our platform.

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