Service Request Form Please complete the form below to request Adult Foster Care (AFC), Home Help, Non-Emergency Medical Transportation (NEMT), or Guardianship Services. A team member will contact you within 1–2 business days. Services Requested (Select all that apply) *Adult Foster Care (AFC)Home Help ServicesNon-Emergency Medical Transportation (NEMT)Guardianship ServicesParticipant Information (Person Needing Services)Full Name *Date of Birth *Street Address *CityState/ProvinceZIP / Postal CodePhone Number *Email AddressConfirm Email AddressPreferred Language *Medicaid or Insurance ID # *Does the participant have any disability or medical condition? *YesNoPlease Describe *Referrer Information (If Different From Participant)Relationship to ParticipantYour NamePhone NumberEmail AddressOrganization (if applicable)Care Needs or Reason for Request *Preferred Contact Method *Option 1Option 2Best Time to Contact *MorningAfternoonEveningUpload Supporting Documents (Optional)You may upload any relevant files (e.g., ID, Medicaid card, referral form)Drag and Drop (or) Choose FilesConsent & Acknowledgment *I understand that the information provided will be kept confidential and used solely for service coordination. I agree to be contacted by Integrated Home Care Agency.Submit Request