ADRC Referral To Income Maintenance For Managed Long …



STATE OF WISCONSIN DEPARTMENT OF HEALTH SERVICESDivision of Public HealthF-02053 (03/09/2021)854661-257908CIP00CIPADRC referral to income maintenance For Managed Long-TeRM Care ServicesDate of Referral to (IM)RFA/Case Number FORMTEXT ????? FORMTEXT ?????Name – ADRC Staff Completing FormPhoneEmail FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Referral for: FORMCHECKBOX Family Care FORMCHECKBOX IRIS FORMCHECKBOX PACE FORMCHECKBOX Partnership FORMCHECKBOX Medicare Savings Program FORMCHECKBOX MA Only FORMCHECKBOX MAPP FORMCHECKBOX Divestment FORMCHECKBOX Asset AssessmentLong-Term Care Functional Screen Eligibility Determined on Date:The LTCFS Eligibility Results page must also be submitted with this referral. FORMTEXT ?????If the individual was previously determined functionally eligible, please include the first date on which the individual was determined functionally eligible: FORMTEXT ?????Type of Application Process Requested: FORMCHECKBOX Face-to-Face FORMCHECKBOX Mail FORMCHECKBOX PhoneApplicant is Currently Enrolled in: (If Applicable) FORMCHECKBOX MAPP FORMCHECKBOX MA Waiver Program FORMCHECKBOX Institutional MA FORMCHECKBOX SSI FORMCHECKBOX BadgerCare Plus FORMCHECKBOX Medicaid Savings Program FORMCHECKBOX Katie BecketName – Applicant (Last, First, MI)DOBMedicaid ID FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Street AddressCityStateZip CodePhone FORMTEXT ????? FORMTEXT ????? FORMTEXT WI FORMTEXT ????? FORMTEXT ?????Marital StatusLiving Arrangement FORMCHECKBOX Single FORMCHECKBOX Divorced FORMCHECKBOX Married FORMCHECKBOX Widowed FORMCHECKBOX Separated FORMCHECKBOX Legally Separated FORMCHECKBOX Own Home/Apartment FORMCHECKBOX Nursing Home FORMCHECKBOX ICF-MR FORMCHECKBOX CBRF FORMCHECKBOX AFH FORMCHECKBOX RCAC FORMCHECKBOX Other – Specify: FORMTEXT ?????County of ResidenceCounty of Responsibility FORMTEXT ????? FORMTEXT ?????Protective PlacementProtective Placement County of Venue (if applicable) FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????Name – Contact PersonPhone FORMTEXT ????? FORMTEXT ?????Relationship to Applicant (e.g., guardian of person, guardian of finances, POA, Rep. payee, authorized representative, son, daughter) FORMTEXT ?????Street AddressCityStateZipPhone FORMTEXT ????? FORMTEXT ????? FORMTEXT ?? FORMTEXT ????? FORMTEXT ?????Anticipated Program Start Date:$ FORMTEXT ?????Special Housing Amount in Substitute Care – Rent only from Room and Board costs:$ FORMTEXT ?????Medical/Remedial Expenses: Attach Form F-00295 if applicable:$ FORMTEXT ?????The following documents are attached: FORMCHECKBOX Family Care Program Enrollment Form F-00046 FORMCHECKBOX IRIS Authorization Form F-00075 FORMCHECKBOX PACE and Partnership Program Enrollment Form F-00533 FORMCHECKBOX LTCFS Eligibility Results Page FORMCHECKBOX Medical and Remedial Expenses Checklist Form F-00295 FORMCHECKBOX Guardianship, POA, Representative Payee Documentation FORMCHECKBOX Declaration Regarding Transfer of Resources Form F-20919D FORMCHECKBOX Medicaid Asset Assessment Form F-10095 FORMCHECKBOX Wisconsin Medicaid for the Elderly, Blind or Disabled Application Form F-10101 FORMCHECKBOX BadgerCare Plus Application Form F-10182 FORMCHECKBOX Medicaid/BadgerCare Plus Verification Documents FORMCHECKBOX MADA Form F-10112 and ADDD Form F-14014 FORMCHECKBOX Other Documentation – Describe: FORMTEXT ????? ................
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