Fillable Caregiver Organizer Your Care Organizer (United Healthcare)

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Caregiver Organizer Your Care Organizer (United Healthcare)

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The Caregiver Organizer Your Care Organizer (United Healthcare) form is 32 pages long and contains:

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  • 28 check-boxes
  • 587 other fields

Country of origin: US
File type: PDF

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Your Care Organizer
Stay organized and have the important information you need when you need it.
Complete this document and share a copy with your spouse, adult child, Power of Attorney (POA),
attorney or someone you trust. Keep it in a secure location (e.g., safety deposit box or home safe).
2
Stress less knowing that you’re prepared.
This Organizer helps you record important
information that may be needed, from medical
records to household and financial details. You can
fill this out on your computer and then print it. Or, you
can download and print the pages to fill out by hand.
Bring this Organizer to use as a reference at doctor visits.
It can also help care team members stay connected
by making sure everyone has the same information.
Copies of this organizer have been given to:
Name:
Relationship:
Phone:
Name:
Relationship:
Phone:
Name:
Relationship:
Phone:
Date last updated
(write in pencil):
Date originally
completed:
Review this
tool annually.
Have all personal
records in one place.
3
Table of Contents
Personal & Health 4
Personal Information 4
Notification List in Case of Emergency 4
Health Care Providers 4
Health Issues 6
Medication Information 6
Insurance Information 7
Other Important Information 10
Household 11
Home Security System 11
Home Safe Information 11
Housing Information: Primary Home 11
Housing Information: Secondary Home 13
Automobile, RV, Boat, and/or Other 14
Finances, Legal, Legacy Planning & More 15
Accountant & Tax Information 15
Financial Information 15
Credit Card Information 16
Health Savings Account 17
Investment & Retirement Accounts 17
Legal Information 18
Online/Social Media Accounts 18
Pet Care 19
Funeral & Burial Arrangements 19
4
Personal & Health
Personal Information
Name:
Address:
City: State: ZIP: County:
Home phone: Cell phone:
Date of Birth (DOB):
Social Security Number (SSN):
Email:
Notifications List (in case of Emergency)
Primary contact
Name: Phone:
Relationship: Special instructions:
Other contacts
Name: Phone:
Relationship: Special instructions:
Name: Phone:
Relationship: Special instructions:
Employer
Supervisor: Phone:
Health Care Providers
Primary physician:
Address:
Phone:
5
Pharmacy:
Address:
Phone:
Current medication list location:
Specialist:
Address:
Phone:
Specialty:
Specialist:
Address:
Phone:
Dentist:
Address:
Phone:
Eye doctor:
Address:
Phone:
Hospital preference:
Address:
Phone:
Home health care provider:
Phone:
Case manager:
Medical equipment provider:
Phone:
Oxygen provider:
Phone:
6
Health Issues
List health issues, implanted items, specific instructions and any other health concerns.
Allergies:
Medication Information
Use this section to record all medications, including the proper dosage amounts and schedule, as
well as pharmacies.
If you choose to print this organizer, other documents to consider storing in this section:
• Formulary (list of covered drugs)
• Copies of written prescriptions
Medication:
Reason for prescription:
Dosage: # of times per day:
A.M. P.M. Both
Take medication: With food On an empty stomach
Side effects (if any):
Prescribing doctor: Pharmacy prescription #:
Pharmacy: Phone:
Date started: Date discontinued (if any):
Medication:
Reason for prescription:
Dosage: # of times per day:
A.M. P.M. Both
Take medication: With food On an empty stomach
Side effects (if any):
Prescribing doctor: Pharmacy prescription #:
Pharmacy: Phone:
Date started: Date discontinued (if any):
7
Medication:
Reason for prescription:
Dosage: # of times per day:
A.M. P.M. Both
Take medication: With food On an empty stomach
Side effects (if any):
Prescribing doctor: Pharmacy prescription #:
Pharmacy: Phone:
Date started: Date discontinued (if any):
Medication:
Reason for prescription:
Dosage: # of times per day:
A.M. P.M. Both
Take medication: With food On an empty stomach
Side effects (if any):
Prescribing doctor: Pharmacy prescription #:
Pharmacy: Phone:
Date started: Date discontinued (if any):
Insurance Information
Medicare #: Medicaid #:
Health insurance:
Issuer: Account #:
Agent name: Agent phone:
Premium amount:
Due date: Auto pay from:
Website:
Username: Password:
8
Health insurance:
Issuer: Account #:
Agent name: Agent phone:
Premium amount:
Due date: Auto pay from:
Website:
Username: Password:
Dental insurance:
Issuer: Account #:
Agent name: Agent phone:
Premium amount:
Due date: Auto pay from:
Website:
Username: Password:
Eye care insurance:
Issuer: Account #:
Agent name: Agent phone:
Premium amount:
Due date: Auto pay from:
Website:
Username: Password:
Home insurance:
Issuer: Account #:
Agent name: Agent phone:
Premium amount:
Due date: Auto pay from:
Website:
Username: Password:
9
Life insurance:
Issuer: Account #:
Agent name: Agent phone:
Premium amount:
Due date: Auto pay from:
Website:
Username: Password:
Long term care insurance:
Issuer: Account #:
Agent name: Agent phone:
Premium amount:
Due date: Auto pay from:
Website:
Username: Password:
Car insurance:
Issuer: Account #:
Agent name: Agent phone:
Premium amount:
Due date: Auto pay from:
Website:
Username: Password:
Other insurance:
Issuer: Account #:
Agent name: Agent phone:
Premium amount:
Due date: Auto pay from:
Website:
Username: Password:
10
Other Important Information
Any items in storage: Yes No
Address: Phone:
Newspaper provider(s): Phone to stop delivery:
Local post office address: Phone:
Religious community:
Contact name: Contact phone:
Birth certificate location:
Marriage certificate location:
Divorce decree location:
Military discharge papers, location:
11
Household
Home Security System
Provider: Phone:
Alarm code:
Special instructions:
Home Safe Information
Safe:
Location:
Contents:
Location of safe key: Combination:
Housing Information: Primary Home
Mortgage/rental company: Phone:
Address: Account #:
Website:
Username: Password:
Mortgage/rent amount:
Due date: Auto pay from:
Location of deeds and property titles:
Electric company: Phone:
Account #: PIN:
Website: Auto pay from:
Username: Password:
12
Gas company: Phone:
Account #: PIN:
Website: Auto pay from:
Username: Password:
Water company: Phone:
Account #: Auto pay from:
Website:
Username: Password:
Sewer company: Phone:
Account #: Auto pay from:
Website:
Username: Password:
Home phone company: Phone:
Account #: Auto pay from:
Website:
Username: Password:
Cell phone company: Phone:
Account #: PIN:
Website: Auto pay from:
Username: Password:
Cable company: Phone:
Account #: Auto pay from:
Website:
Username: Password:
Internet provider: Phone:
Account #: Auto pay from:
Website:
Username: Password:
13
Garbage company: Phone:
Account #: Auto pay from:
Website:
Username: Password:
Housing Information: Secondary Home
Mortgage/rental company: Phone:
Address: Account #:
Website:
Username: Password:
Mortgage/rent amount:
Due date: Auto pay from:
Location of deeds and property titles:
Electric company: Phone:
Account #: PIN:
Website: Auto pay from:
Username: Password:
Gas company: Phone:
Account #: PIN:
Website: Auto pay from:
Username: Password:
Water company: Phone:
Account #: Auto pay from:
Website:
Username: Password:
Sewer company: Phone:
Account #: Auto pay from:
Website:
Username: Password:
14
Home phone company: Phone:
Account #: Auto pay from:
Website:
Username: Password:
Cell phone company: Phone:
Account #: PIN:
Website: Auto pay from:
Username: Password:
Cable company: Phone:
Account #: Auto pay from:
Website:
Username: Password:
Internet provider: Phone:
Account #: Auto pay from:
Website:
Username: Password:
Garbage company: Phone:
Account #: Auto pay from:
Website:
Username: Password:
Automobile, RV, Boat, and/or Other
Make: Model: Year:
License plate #: VIN #:
Make: Model: Year:
License plate #: VIN #:
Make: Model: Year:
License plate #: VIN #:
Make: Model: Year:
License plate #: VIN #:
15
Finances, Legal, Legacy
Planning & More
Accountant & Tax Information
Accountant:
Address:
City: State: ZIP:
Location of past & current filings:
Financial Information
Bank: Phone:
Address: Website:
City: State: ZIP:
Username: Password:
Checking account #: Savings account #:
Other account #:
Debit card #: PIN:
Auto payments from/to:
Bank: Phone:
Address: Website:
City: State: ZIP:
Username: Password:
Checking account #: Savings account #:
Other account #:
Debit card #: PIN:
Auto payments from/to:
16
Safe-Deposit Box(s)
Location:
Contents: Location of box key:
Credit Card Information
Credit Card: Phone:
Account #: Exp. date:
Website:
Username: Password:
Auto payments to:
Special information (rewards, etc.):
Credit Card: Phone:
Account #: Exp. date:
Website:
Username: Password:
Auto payments to:
Special information (rewards, etc.):
Credit Card: Phone:
Account #: Exp. date:
Website:
Username: Password:
Auto payments to:
Special information (rewards, etc.):
17
Health Savings Account
Company:
Account #: Phone:
Website:
Username: Password:
Debit card #: PIN:
Auto payments from/to:
Investment & Retirement Accounts
Investment company:
Financial advisor: Phone:
Account and account #:
Website:
Username: Password:
Investment company:
Financial advisor: Phone:
Account and account #:
Website:
Username: Password:
Investment company:
Financial advisor: Phone:
Account and account #:
Website:
Username: Password:
18
Legal Information
Attorney: Phone:
Address:
City: State: ZIP:
Email:
Legal documents (check all documents that are completed & who has copies)
Will & testament
Copies given to:
Power of attorney
Copies given to:
Advance directive/living will
Copies given to:
Do Not Resuscitate (DNR) order
Copies given to:
Other:
Copies given to:
Other:
Copies given to:
Online & Social Media Accounts
Email: Password:
Email: Password:
Facebook:
Username: Password:
Twitter:
Username: Password:
Instagram:
Username: Password:
Other:
Username: Password:
19
Pet Care
Veterinarian clinic: Phone:
Address:
City: State: ZIP:
Instructions for pet care:
Back-up for pet care:
Address: Phone:
City: State: ZIP:
Funeral & Burial Arrangements
Funeral home: Phone:
Address:
City: State: ZIP:
Organs to be donated?
Yes No
Special arrangements have made for funeral and burial/cremation:
20
Notes:
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Caregiver Organizer Your Care Organizer (United Healthcare)

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Completed 27 February 2021

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