White Card Intake

White Card Intake Form

If you or a loved one is a former energy worker with a Department of Labor (DOL) White Card through the EEOICPA program, Lifeline Home Health is here to help. We specialize in coordinating skilled nursing, home care, and support services for clients covered under Part B and Part E.

Our compassionate care team will walk you through every step — including working directly with your case manager and helping you understand your benefits.

Please complete the intake form below to begin your care coordination process.

Client Information

First Name

Last Name

Your Date of Birth

Phone

Current Home Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Preferred Contact Method

Phone

Text

DOL White Card Information

Do you have a current DOL white card?

Yes

In Progress

Unsure

Are you enrolled under:

Part B

Part E

Both

I don't know

Authorized Representative (if applicable)

First Name

Last Name

Phone

Relationship to the client:

Current DOL Case Manager (if known)

First Name

Last Name

Services Requested

Which services are you currently seeking? (check all that apply)

RN Skilled Nursing

HHA / CNA Assistance

Homemaking / Housekeeping

Medication Management

Wound Care

Companionship & Support

Physical / Occupational Therapy (via referral)

Help understanding my benefits

Other

If "Other", please describe:

Preferred schedule or availability for visits:

Do you currently have a home health agency?

Yes

In transition / looking to switch

Not sure

Do you want us to help coordinate switching agencies or starting care?

Yes, please help me get started

I just want to learn more for now

I need help understanding my benefits.

Health & Safety Details

Primary Diagnoses or Conditions

Current medical concerns or limitations:

Is your home safe for home health visits? (electricity, plumbing, no hazards)

Yes

Needs Improvement

Unsure

Emergency Contact

First Name

Last Name

Phone

Consent & Next Steps

Do you give Lifeline Home Health permission to contact you to begin services, review your DOL eligibility, and coordinate care?

Yes

Electronic Signature (type your name to sign electronically)

Today's Date

SMS Opt-in

I agree to receive text messages from Lifeline Home Health. I understand message and data rates may apply. I have read and agree to the SMS Consent Policy.

Client Information

DOL White Card Information

Authorized Representative (if applicable)

Current DOL Case Manager (if known)

Services Requested

Health & Safety Details

Emergency Contact

Consent & Next Steps

SMS Opt-in

Now Open! Lifeline Home Health is now Accepting Clients — Call 509-851-0033