DEPARTMENT OF HEALTH SERVICES Division of Long Term Care F-22678 (07/2008)
COMMUNITY RELOCATION INITIATIVE INITIAL INFORMATION AND FUNDING ESTIMATE
Completion of this form is voluntary. If not completed, the request cannot be processed. The personally identifiable information is being collected to process potential program eligibility. Completed forms will only be accessed by staff processing the request.
Name Applicant Date of Birth Medicaid Number
County Applying Name of Nursing Home Is the Nursing Home Closing or Downsizing? Yes No
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Date of Planned Relocation/Discharge
Date of Admission to Nursing Home
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Document why this person's nursing home stay is expected to be long term
Proposed New Living Arrangement This cost includes the following estimated daily amounts: Supportive Home Care CBRF Service Per diem Adult Day Care One time waiver costs: Adaptive Aids Care management
Estimate of the person's daily waiver cost (Do not include room and board, cost share or one time waiver costs.) Transportation Other
Waiver Allowable Home Modifications
Room and board costs in substitute care setting
Estimate of the daily Medicaid card services person will need (hours/day; times/week): MA Personal Care Home Health (RN / Therapies) Other Known, e.g., Transportation., DME, DMS
Will this person receive SSI upon return to the community? Will this person access the SSI Exceptional Expense (SSI-E) benefit? Will one time funding be needed for start-up costs (clothing, groceries) not covered by CIP II SPC 106.03 or 604.04? Explain cost and items
Yes Yes Yes
No No No
Amount of person's income: SIGNATURE Care Manager Telephone Number Fax Number Name Care Manager (Print) E-Mail Address Date Signed
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Fax completed form to Bureau of Long-Term Support/Community Relocation Initiative at 608-267-2913 For Bureau of Long-Term Support use
Estimate not able to be approved:
Estimate approved by BLTS on:
no Medicaid data available
BLTS will hold as pending
Estimate approved. Develop and submit waiver application packet to TMG for FINAL approval of CRI plan and funding.
Total Estimate Amount Approved: Estimate approval faxed to county on:
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