I Am Unique's Service Area

** 1-2 hour radius surrounding Raleigh service provided in the following counties and others as requested:

1.	Alamance	9.	Johnston
2.	Cumberland	10.	Nash
3.	Chatham	11.	Orange
4.	Durham	12.	Randolph
5.	Franklin	13.	Vance
6.	Granville	14.	Wake
7.	Guilford	15.	Warren
8.	Halifax	16.	Wilson

Approved Providers for:

•	Blue Cross/Blue Shield
•	State Employees Health Plan
•	Community Care Program

•

Medicaid • Private Duty Nursing • Personal Care Services • HIT - Home Infusion Therapy

•

Community Alternatives Program • (CAP/C) Children • Cap/C Personal Care Service • Hourly Nursing • Respite Care - In Home • (CAP/DA) Disabled Adults • In Home Aide Level II and III • Respite Care - In Home • (CAP/MRDD) Mentally Retarded/Developmentally Disabled • Personal Care Services • Respite Care Noninstitutional, Unskilled • Respite Care Noninstitutional, Skilled • Supported Living I, II, & III • Community Inclusion

Client Information Feedback

Name:
Address:
City/State:
Daytime Phone:
Evening Phone:
Age:
Requested Service:

Personal Care Services - Nursing Assisted Care

Private Duty Nursing - Licensed Nursing Care

Number of Hours of Care per Day

Diagnosis:

Payor Source:

Private Pay

Medicaid

Private Insurance:

The information which you give in completing this form will be forwarded to the designated party for its use and will not be used by Real Pages for any other purpose or provided by us to any other parties. If you wish information concerning the privacy policy or the designated recipient, you should contact them directly.

If you are interested in I Am Unique providing care for you or someone you know, please complete the form above and submit. An agency representative will contact you. Thank You.

Hours:  Monday - Friday 8:30 am - 5:00 pm

I Am Unique
Special Care and Case Management
3211 Bramer Dr. • Suite F • Raleigh, NC  27604
(919) 981-0790 • (800) 566-8648 • Fax:  (919) 981-0135
E-Mail Us at: ahines@btitelecom.net

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