Checklist - User Intake





Checklist - User Intake: Policies, Procedures and Workflow


ü      Eligibility guidelines for each type of service


ü      Referral requirements


ü      User intake by telephone  


ü      User intake in person


ü      Client record-keeping in compliance with privacy policy


ü      User information for all services


ü      Fees, if applicable, and disclosure packages


ü      Develop user intake workflow




Suggested Documentation




Eligibility for services

Eligibility guidelines for each service

How to communicate eligibility guidelines to prospective user

User intake

Acceptable referral sources, procedures

Intake forms

How to process telephone referral

How to process new user in person

Prescription requirements

Identify devices requiring prescription, appropriate prescribing source (esp. if Medicaid/Medicare involved)

How to determine devices requiring prescriptions, which professionals can prescribe; how to acquire Rx


Types of files

Information collected, forms

Storage and security

Privacy protection, forms, access controls

Retention practices


How to create a new user record and complete forms

How to disclose privacy practices to user and get signatures acknowledging receipt of information

How, where to store user records to ensure privacy compliance

Behaviors to avoid that result in inappropriate privacy violations


User information

Statement of services offered

Statement of privacy practices

Disclosure of fees, if any

When, how to provide information to new user



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This work is supported under a five-year cooperative agreement # H235V060016 awarded by the U.S. Department of Education, Office of Special Education and Rehabilitative Services, and is administered by the Pass It On Center of the Georgia Department of Labor – Tools for Life.  However, the contents of this publication do not necessarily represent the policy or opinions of the Department of Education, or the Georgia Department of Labor, and you should not assume endorsements of this document by the Federal government or the Georgia Department of Labor.











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Other Information

Title: Checklist - User Intake
Module: User Services
Author: Trish Redmon
Audience: Implementer
Sub Title: Policies and Procedures
Organization Source: Pass It On Center
Last Reviewed: 10-25-2009 6:58 PM