Instructions
This is an application for an evaluation visit from CentraCare. There is no cost for requesting an evaluation. To request an evaluation:
Complete Section A
This is information about the person MAKING the referral. Centracare will be in contact with this person.
Complete Section B
This is information about the prospective participant. This is the person who will receive the services. This person MUST
  • Be 55 years or older
  • Live within Calhoun County, Michigan
  • Meet nursing home level of care as determined by the Michigan Medicaid Nursing Facility Level of Care Determination Tool
  • Determined to be able to live safely in the community
Click Apply
Centracare will receive your online application for an evaluation and contact the Referrer to set up an evaluation.

More Enrollment Information
SECTION A - Information on Referral Source
Complete the following information about the person making the referral
Referrer First Name
Referrer Last Name
Phone Number
Alternate Phone Number
Referrer Email Address
What is your relationship to the prospective participant?
SECTION B - Prospective Participant
Complete the following information about the prospective participant
Participant First Name
Participant Last Name
Date of Birth e.g. 5/25/1930
Qualifications Checklist