Your form "Client Referrals " has received the following response:
11/28/2018 15:02
Completion time: 13 min. 45 sec.

Client Name and Address
Ruby Marks
806) 747-8888
Client Email

1115 34th Street
Lubbock
TX
79411
County
Lubbock

Additional Client Information
Client's Age at Referral: 66
DOB: 7/6/1952
Client's Gender: Female
Client's Ethnicity: Other

Is this a hospice patient?: No
Is this a dialysis patient?: No
Is this a handicapped person living alone?: Yes
Did this person serve in the military?: No

Client Financial Information
Is there a financial need, based on your agency's guidelines? No
Does the Client Own or Rent their home? Own

Caretaker/Other Contact Information
Caretaker /Other Contact  Name

Caretaker/Other Contact Phone

Ramp Information
Where is the ramp needed? Front or house
Description of obstacles(s): Doorway.

Details of mobility
Our member is confined to a wheelchair. She has not left her home in several months. 
She has visiting doctors. Aetna does not provide financial assistance, and I told member 
she may have to pay some costs for the ramp.

Is there an existing dangerous ramp at the client's home? No

Referring Social Worker Information
Referring Social Worker Full Name: Barbara Morris
Name of Referring Agency: Aetna Community Care
Referring Social Worker's Phone: (346) 242-2859
Referring Social Worker's Email: morrisb@aetna.com