Minority Access Pool System

A FREE Community Service of SCHAS

Client's Application

Please fill out the form below, or contact Cassandra Coleman to apply by mail. (865) 329-0097

Client Name
Date of Birth
Home Address
City
Phone
Physician
Phone
Insurance
Medical Diagnosis
Reasons for Referral
Other Agencies working with Client
Client Location:	Home Hospital Other
Placement Needed:	Now Near Future Later
Nursing Preferences	1.
	2.
	3.
Contact Person
Phone
Address
County

Did you Know?

~Did you know that not all nursing facilities are Medicare Medicaid Certified?

Minority Applicant Pool System
209 Bearden Place
P.O. Box 54807
Knoxville, TN 37927
(865) 329-0097
FAX: (865) 637-3817
E-mail:

Program services are available to all eligible seniors regardless of ethnicity.
This project is funded under an agreement with the Tennessee Department of Health