Begin Your Care Journey

Please complete this brief eligibility assessment by telling us about the home care services you’re looking for, your insurance type, and your contact details. Once submitted, we’ll confirm your eligibility & match you with the most appropriate SafeLife support team. A Care Coordinator will be in touch within one business day to guide you next.

Eligibility Form

Answer a few quick questions so we can confirm eligibility and match you with the right Safe Life services.

Which type of care are you interested in?

Select all that apply

Home HealthHome Care – Private DutyHome Care – CCPHospicePalliative

Personal Details

First Name: *

Last Name: *

Date of Birth *

Insurance Information

Insurance Type

Insurance Member ID / SSN :

Contact Information

Phone Number

Email Address: *

Service-Area Address

Street Address: *

Address Line 2 (optional) :

City

State/Province

ZIP / Postal Code

Consent & Submit

By submitting this form, you certify that the information provided is accurate and consent to Safe Life Home Health Care contacting you via phone, SMS, or email. Your personal data is protected in accordance with HIPAA regulations and our Privacy Policy.

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For Home Health Services

Call us at

For Home Care and Private Duty Services

Call us at

or email

Your questions are always welcome

Ready to Begin?

Want to find out if you or a loved one qualifies for CCP?