WeCare ServicesTM 

Personal Health Nursingfor Seniors receiving Title III 

Home-Delivered Meals 

Appendix Documents
Table of Contents

Appendix Documents..............................................................................................................................................................................1

Appendix A – WeCare Welcome Letter ....................................................................................................................................3

Appendix B – Individual Member Participation and Release Form.....................................................................4

Appendix C – WeCare Individual Intake Form....................................................................................................................5

Appendix D – Physician Information Release Form........................................................................................................6
Appendix A – WeCare Welcome Letter
WELCOME LETTER

Dear Member,

We at WeCare Services would like to welcome you to the WeCare program. You can be assured 

that WeCare will provide the following services to you at no cost to you.

• Provide a Personal Health Nurse to manage your healthcare needs

• Help members connect with their primary care doctors to manage sudden change 

in condition

• Help members avoid unnecessary ER visits and hospitalization

• Calls members weekly to check on their well-being

• Connect members to resources such as Home Health Care, Rehabs, Transportation 

to their doctors’ office, adult daycare, Hospice, PACE

• Provide ongoing healthcare services

• Complete medical necessity papers

• Provide Medical Homes for members with no Family Doctors

• Complete Power of Attorney papers if needed

Again, welcome to WeCare. We look forward to serving you.

Sincerely,

Kemi Sanni, DNP, MSN, APRN, CRNP, FNP-BC

Program Director

302-265-8686 (Cell)

302-459-3900 (Office)

302-503-7197 (Fax)

ksanni@wecareservices.org (Email).

This project was supported, in part by grant number 90INNU0030-01-00 from the U.S. 

Administration for Community Living, Department of Health and Human Services, Washington, 

D.C. 20201.
Appendix B – Individual Member Participation and 

Release Form
PARTICIPATION AND

RELEASE OF INFORMATION AGREEMENT

I, ___________________________________________________________, agree to participate as a client in the 

WeCare Services, a service offered by Education Health and Research International, Inc. (EHRI). 

I understand that this means:

1. WeCare, a program of EHRI, offers healthcare coordination services AT NO COST to me. 

Participation in the WeCare program is voluntary; I am not obligated to participate in the 

WeCare program or accept this service and do so voluntarily. 

2. Once enrolled, the WeCare Coordinator may contact me, and/or my authorized 

representative, and my healthcare providers (hospitals, doctors, therapists, etc.) to 

discuss my healthcare needs and to access my health information. WeCare will use and 

disclose any personally identifiable information about me only to provide healthcare 

coordination services as authorized by me, or as otherwise set forth herein. Otherwise, 

WeCare will keep all individually identifiable information about me confidential.

3. By signing where indicated below, I hereby authorize the WeCare Coordinator to obtain 

healthcare information about me from the providers described below, and to use and 

disclose the health information so received to create and update a Care Plan uniquely for 

me. My Care Plan will be used as a planning tool by WeCare to help coordinate my 

healthcare needs, which will be based on the treatment prescribed by my medical 

providers.

4. WeCare may use information about services rendered to WeCare clients to review and 

evaluate the effectiveness of the WeCare Program. By signing where indicated below, I 

authorize the WeCare Program to use and disclose medical and other information for 

such survey, study, or research related to the WeCare Program as long as individually 

identifiable information about me is not made public.

5. I can withdraw from the WeCare Program at any time, for any reason, without any 

reprisal or interruption to any of my other services.

CLIENT RIGHTS

 Receive all WeCare Program services without discrimination based on gender, sexual 

orientation, religion, age, race, or culture.

 Be treated with courteous consideration, respect, dignity, and recognition of individuality.

 Be assured of confidential treatment of records, including but not limited to, my Care Plan, 

maintained by WeCare. Except with respect to the healthcare coordination services 
Authorization to Disclose Information 

ACTIVE.125774379.02

provided by WeCare and as otherwise described herein, the release of any records about 

me outside of WeCare is not permitted without my prior written authorization.

 Voice a complaint or suggest a change in services without being threatened or 

discriminated against, and without the fear of any impact on any WeCare or MMC services 

that I am receiving.

CLIENT RESPONSIBILITIES 

 Provide complete, accurate, and up-to-date contact and health status information.

 Participate and express opinions and priorities in the development of a personal WeCare 

Care Plan.

 Follow medical advice and treatment recommendations provided by my personal 

physicians or other health personnel.

 Ask questions and seek information when something is not clear or understandable.

A copy of this form is as valid as the original. My name and signature below acknowledge my 

receipt and review of this information. This Agreement is active until I am no longer a 

participant in the WeCare Program.

_______________________________________________ __________________________________________

Client Name (please print) Date

_______________________________________________ __________________________________________

 Client Signature Date

To voice a complaint or concern about the services received, please contact:

WeCare Services Program Director, Kemi Sanni, at (302) 265-8686

This project was supported, in part by grant number 90INNU0030-01-00 from the U.S. Administration for 

Community Living, Department of Health and Human Services, Washington, D.C. 20201.
Authorization to Disclose Information 

ACTIVE.125774379.02

I hereby authorize the disclosure of my individually identifiable health information as described 

below. I understand this authorization is voluntary. I understand that if the organization or 

persons authorized to receive the information is not a health plan or health care provider, the 

released information may no longer be protected by federal privacy regulations.

 I understand that I may see and copy the information described on this form if I ask for it, 

and that I get a copy of this form after I sign it.

 I understand that this authorization will expire one year after the date that appears on this 

form.

 I understand that I may revoke this authorization at any time by notifying the person or 

organization providing the information in writing, but if I do, it will not affect any actions 

taken before the revocation is received.

 A photocopy of the original of this authorization shall have the same effect as the original.

 _____ _____ 

Signature of WeCare Program Client or Client’s representative Date 

Printed name of Client or Client’s representative: ________________________ (Relationship)
Appendix C – WeCare Individual Intake Form
WECARE INDIVIDUAL INTAKE FORM 

This form is obtained verbally on every client immediate to their signed WeCare consent. 

This project was supported, in part by grant number 90INNU0030-01-00 from the U.S. 

Administration for Community Living, Department of Health and Human Services, Washington, 

D.C. 20201.
Appendix D – Physician Information Release Form
Date: __________

Dear Provider,

Your patient, _______________________________________ is a member of WeCare 

Services. WeCare serves as the Personal Health Nurse to Modern Maturity Center meal 

recipients, Cheer meal recipients, La Red patients, and Polaris Discharged Patients.

Your patient has signed the authorization to disclose medical information to WeCare to enable

us to familiarize ourselves with their medical conditions and to discuss their conditions with their 

providers. 

WeCare Personal Health Nurses call your patients weekly to check on their well-being with the 

intention to prevent unnecessary hospital admissions and deescalate acute medical conditions. 

During the calls, any change in conditions will be communicated to your office for prompt 

interventions.

WeCare does not treat, diagnose, or prescribe to their members, but act as a liaison between 

the members and their providers.

We will appreciate your collaboration to help ensure that your patients’ well-being remained our 

top priority. You can reach out to me below for any further questions or concerns. 

Thank you.

Kemi Sanni, DNP, MSN, RN

Program Director

Cell: 302-265-8686 

Office: 302-459-3900

Fax: 302-503-7197 

Email: ksanni@wecareservices.org

This project was supported, in part by grant number 90INNU0030-01-00 from the U.S. Administration for 

Community Living, Department of Health and Human Services, Washington, D.C. 20201.