AAA Home Care
324 B Caldwell Blvd.
Nampa, ID 83651
466-3196
1-800-400-3196
Mailing Address: PO Box 1368 Nampa, ID 83653
Email: mail@aaahomecare.com

To: Regional Medicaid Unit______________

I have chosen AAA Home Care as my Personal Assistance Agency.

I authorize the Regional Medicaid Unit to release a copy of my Acknowledgement of Service Delivery and UAI (Uniform Assessment Instrument) to AAA Home Care:

This is a change of agencies: Y N

I plan to start with AAA Home Care on____________________.

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Participant Name Printed


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AddressDate of Birth


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City & ZipMedicaid ID #


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Participant SignatureDate