Contact Us About Your Care Needs

Receive 10% off your first four week's service when you order your In-Attendant & Personal Care. Here's How:

1. Complete and submit the Contact Us Web form.
2. Use AccentCare to obtain applicable services.
3. AccentCare will apply a 10% discount to the first two (2) bi-weekly invoices.
4. Discount not applicable to costs reimbursed by insurance.

*First four weeks of service must be completed and paid to receive the 10% discount. Limit one discount per customer per promotion. Discount must be presented at the time of Start of Care. May not be combined with any other rebate, coupon, discount or promotion.

Please complete the Contact Us form with your information. This request will be forwarded to the appropriate client liaison representative.

Denotes required Field Your Contact Information First Name Last Name Address City State (select a State) Alabama Alaska Arizona Arkansas California Colorado Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Washington West Virginia Wisconsin Wyoming Zip/Postal Code Email Telephone I prefer to be contacted by (Please select) No Preference Telephone Email Requested Services  (Check one or more) Companion Services Live In Attendant & Personal Care Geriatric Care Management Meal Preparation Homecare / Personal Care Transportation Home / Safety Monitoring   Requesting information for Name City State (select a State) Alabama Alaska Arizona Arkansas California Colorado Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Washington West Virginia Wisconsin Wyoming Relationship: (Please select) Friend Grand Parent In Law Parent Self Sibling Someone Else Spouse Gender: (Please select) Female Male Age: Current Care: (Please select) At Home - Independent Living At Home - Receiving Services Facility - Assisted Living Facility - Hospital Facility - Nursing Home Facility - Rehabilitation Facility - Skilled Nursing Care recipient view about assistance services (Please select) Aware - Receptive Aware - Reluctant Aware - Opposed Unaware Care recipient general medical condition (Please select) Self sufficient- No Medications Self sufficient- Some Medications Needs Assistance Needs Significant Assistance Care recipient existing medical conditions (Check one or more) ALS Hypertension / High Blood Pressure Alzheimer's / Dementia Incontinence Ambulatory Problems Joint Replacement Arthritis Osteoporosis Cancer Parkinson's Colostomy Respiratory Disease Depression Stroke Diabetes Surgical Recovery Eye Disease Disease or Condition Not Listed Heart Disease None/Unsure High Cholesterol Other Need to begin services (Please select) Immediately Within 2 Weeks Within 4 Weeks Within 8 Weeks Primary payer source for client care services? (Please select) Health Insurance Long Term Care Insurance Medicaid Medicare Private Pay Other How did you hear about AccentCare Comments - Include information that will assistance our client liaisons to coordinate services