COMMUNITY ALTERNATIVES PROGRAM FOR CHILDREN AND ... - NC
[Pages:2]COMMUNITY ALTERNATIVES PROGRAM FOR CHILDREN AND DISABLED ADULTS (CAP/C & CAP/DA) REFERRAL REQUEST
Write legibly and complete both pages of this form. All fields are required. NC Medicaid staff may contact you for additional information to assist in processing your referral request. Incomplete responses to the referral request may result in a delay in processing your request or a complete void of your referral request. Submission of this form does not guarantee enrollment into the CAP/C or CAP/DA waiver.
Fax completed forms to NC Medicaid at 919-715-0052.
APPLICANT INFORMATION
Service Requested: CAP/C CAP/DA
Date: ____/_____/_________
Applicant's First Name:
Applicant's Last Name:
Applicant has Medicaid?
Yes Pending No
Medicaid ID, if applicable:
Social Security Number: (If Medicaid number is not listed above):
Medicare ID, if applicable
Date of Birth:
/
/
Age:
Gender:
Male Female
Primary contact for this applicant:
Applicant Other representative
If contact person is other than applicant, what is the Contact's First Name:
Contact's Last Name:
Does the applicant have a legal guardian?
Yes No If yes, List the name and contact information of the legal guardian below: Name: Address: Telephone number: Email address:
Current Status/Living Arrangement:
In private residence
In nursing facility
Other temporary living facility In hospital
Primary Language Spoken in Household:
English Spanish/Spanish Creole Other (specify): ________________________________
Is interpreter (spoken) or translator (written) needed or wanted?
Yes No
APPLICANT ADDRESS
Address Line 1: _______________________________________________
Address Line 2: _______________________________________________
City: ______________________________
State: _________
Page 1 of 2
ZIP Code: _______________
Applicant Residence County: _____________________________ Contact Phone: ( ) -
HOSPITAL/NURSING FACILITY/TEMPORARY LIVING FACILITY DETAILS Hospital/Nursing Facility/Temporary Living Facility Name: ___________________________________________________ Anticipated Discharge Date: ____/_____/_________ Name of Discharge Planner (First & Last): _________________________________________________ Discharge Planner Telephone: ( ) -
IMPORTANT DETAILS ABOUT THIS REFERRAL
_______________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ Applicant Add
PRIMARY PHYSICIAN DETAILS
Primary Care Physician: _____________________________________ Physician NPI: __________________________
Primary Physician Practice Name: _____________________________________________________________________
Address: ___________________________________________________________
City: ____________________ State: _________
ZIP Code: _____________
Phone: ( )
-
Fax: ( )
-
REFERRER DETAILS
Referrer Name (First & Last): ____________________________________________________________
Referrer's Relationship to Applicant:
Self Mother Father Sister Brother
Grandmother Grandfather Spouse Son Daughter
Daughter-in-Law Sister-in-Law Niece Nephew Granddaughter
Other relative Friend Professional Other (specify): __________________________ Unknown
Referrer Phone: ( )
-
Referrer Email: _______________________________________________
SUBMITTING AGENCY IDENTIFICATION, IF APPLICABLE
Submitting Agency: ___________________________________________________________________
NPI Number: ___________________________
Locator Code: __________________________
Address: ______________________________________________
City: ______________________________
State: _________
Zip: ______________
Phone: ( ) -
Fax: ( )
-
Submitter Name (First & Last): ___________________________________________________________
Submitter Email: _____________________________________________________________________
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