Intake and Referral



HOME AND COMMUNITY SERVICESIntake and ReferralSection 1. Referent Information1. FULL NAME OF AGENCY OR FACILITY FORMTEXT ?????2. TYPE OF FACILITY FORMTEXT ?????3. REFERENT’S NAME FORMTEXT ?????4. REFERENT’S RELATIONSHIP TO APPLICANT FORMTEXT ?????5. PHONE NUMBER ( FORMTEXT ?????) FORMTEXT ?????EXT. FORMTEXT ?????6. DATE FORMTEXT ?????7. REFERENT’S ZIP CODE FORMTEXT ?????Section 2. Applicant Information1. APPPLICANT’S NAME: LAST, FIRST, MI FORMTEXT ?????2. GENDER FORMCHECKBOX Male FORMCHECKBOX Female3. BIRTH DATE FORMTEXT ?????4. SOCIAL SECURITY NUMBER FORMTEXT ?????5. APPLICANT’S HOME ADDRESSCITYSTATEZIP CODE FORMTEXT ????? FORMTEXT ????? FORMTEXT ?? FORMTEXT ?????6. APPLICANT’S MAILING ADDRESS (IF DIFFERENT)CITYSTATEZIP CODE FORMTEXT ????? FORMTEXT ????? FORMTEXT ?? FORMTEXT ?????7. APPLICANT’S PRIMARY PHONE NUMBER( FORMTEXT ?????) FORMTEXT ?????8. APPLICANT’S EMAIL ADDRESS FORMTEXT ?????9. AUTHORIZED REPRESENTATIVE’S NAMERELATIONSHIP TO APPLICANTTELEPHONE NUMBER: FORMTEXT ????? FORMTEXT ?????( FORMTEXT ?????) FORMTEXT ?????10. IS APPLICANT MARRIED? IF YES, NAME OF SPOUSE: FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????11. IS APPLICANT NATIVE AMERICAN? IF YES, AFFILIATION: FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????12. APPLICANT’S PRIMARY LANGUAGE FORMTEXT ?????DEAF / HEARING IMPAIRED ASSISTANCE NEEDED? FORMCHECKBOX Yes FORMCHECKBOX NoINTERPRETER NEEDED? FORMCHECKBOX Yes FORMCHECKBOX NoSection 3. Applicant Current Location1. APPLICANT’S CURRENT LOCATION / ROOM NUMBER FORMTEXT ?????2. APPLICANT’S CURRENT SETTING (E.G., IN-HOME, NURSING FACILITY, HOSPITAL, ETC.) FORMTEXT ?????3. PHONE NUMBER APPLICANT CAN BE REACHED( FORMTEXT ?????) FORMTEXT ?????4. ADMIT DATE FORMTEXT ?????5. ANTICIPATED DISCHARGE DATE FORMTEXT ?????Section 4. Medicaid Eligibility InformationWashington Apple Health? FORMCHECKBOX Yes FORMCHECKBOX NoMAGI? FORMCHECKBOX Yes FORMCHECKBOX NoACES Client ID Number: FORMTEXT ?????Date Medicaid application was submitted: FORMTEXT ?????FOR NURSING HOME RESIDENTS ONLYIs the client PASRR positive? FORMCHECKBOX Yes FORMCHECKBOX NoIs a PASRR Level II assessment included with this referral? FORMCHECKBOX Yes FORMCHECKBOX NoRUG score: FORMTEXT ????? FORMCHECKBOX Not availableSection 5. Assessment InformationAPPLICANT’S DESIRED SETTING FORMCHECKBOX In-Home FORMCHECKBOX Skilled Nursing Facility Placement FORMCHECKBOX Skilled Nursing Facility Conversion FORMCHECKBOX Assisted Living FORMCHECKBOX Enhanced / Adult Residential Care FORMCHECKBOX Adult Family Home FORMCHECKBOX Enhanced Services FacilityAPPLICANT IS INTERESTED IN: FORMCHECKBOX Adult Day Health FORMCHECKBOX Adult Day Care FORMCHECKBOX Skilled Nursing Services FORMCHECKBOX Nurse Delegation FORMCHECKBOX Caregiver SupportSection 6. Nursing NeedsCHECK ALL THAT APPLY FORMCHECKBOX Toileting FORMCHECKBOX Medication Assistance FORMCHECKBOX Indwelling catheter FORMCHECKBOX Heart Disease FORMCHECKBOX Bathing FORMCHECKBOX Turning / Repositioning FORMCHECKBOX Paralysis FORMCHECKBOX Diabetes FORMCHECKBOX Mobility FORMCHECKBOX Disorientation/Memory Problems FORMCHECKBOX Neurological Disorder FORMCHECKBOX COPD FORMCHECKBOX Personal Hygiene FORMCHECKBOX Skin breakdown/ulcers FORMCHECKBOX Traumatic Brain Injury FORMCHECKBOX StrokeIntake and Referral form for Social Services. Barcode 10570 DSHS form 10-570Purpose: Communication to social services intake regarding an individual requesting a functional assessment for long-term services and supports (LTSS). Initial eligibility for LTSS is done concurrently by both the financial worker and the social worker/case manager.InstructionsPlease type or print clearly and fill out as completely as you can to assist in processing the request for service.Fax form to the Home and Community Services office in your region for intake.If you have questions about submitting the form please contact your regional office at the number below.REGION 1 – Pend Oreille, Stevens, Ferry Okanagan, Chelan, Douglas, Grant, Lincoln, Spokane, Adams, Whitman, Klickitat, Kittitas, Yakima, Benton, Franklin, Walla Walla, Columbia, Garfield and Asotin: 509-568-3767 or 1-866-323-9409; fax 509-568-3772REGION 2N – Snohomish, Whatcom, Skagit, Island, and San Juan 800-780-7094; fax 425-339-4859; Nursing Facility Intake, fax 425-977-6579REGION 2S – King: 206-341-7750; fax 206-373-6855REGION 3 – Pierce, Kitsap, Thurston, Mason, Lewis, Grays Harbor, Pacific, Cowlitz, Clark, Clallam, Jefferson, Skamania and Wahkiakum: 800-786-3799; fax 1-855-635-8305Section 1. Referent Information: Include as much information as is known. If the referent is of relation to the applicant, include this information.Section 2. Applicant InformationFill out all known application information. Include all identifying information. If there is an authorized representative complete this sectionSection 3. Applicant LocationPlease list the applicants currently location and fill out the box that most applies to the applicant’s current setting.Admit date: when was the applicant admitted to the current facility, not needed if in home.Anticipated discharge date: complete if there is a discharge plan from the current location.Section 4. Medicaid Eligibility InformationWashington Apple Health is the WA Medicaid program.MAGI refers to Adults on Medicaid through expansion of the Affordable Care Act.ACES client ID number can be found in a ProviderOne benefit inquiry and is also known as the DSHS number.If the applicant is not eligible for WA Apple Health an application is necessary to receive services, please indicate the date the application was submitted.PASRR information box should be completed only if the applicant is a current resident of a nursing facility. Check the “Yes” box if the applicant required and/or received a PASRR Level II assessment. Indicate RUG score if known. Check N/A if unknown at the time of Intake and Referral.Section 5. Assessment InformationIf the type of service being requested is known please complete this section. If the applicant is requesting residential placement, and the type of placement is known please check the box.Section 6. Personal Care and Nursing Needs Please check all boxes that apply to the applicant. ................
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