Free 51550.FH11 - Indiana

APPLICATION FOR LONG-TERM CARE SERVICES MENTAL HEALTH HOSPITAL / SED WAIVER
State Form 51550 (3-04) / TS 0001

The information contained on this completed form is CONFIDENTIAL according to IC 16-39-2.

Application is for (check one)

Mental Health Hospital
Name of applicant Home address (number and street, apartment number, city, state, ZIP code) Date of birth Sex

SED Waiver
Telephone number ( )

Age

Male MEDICAID STATUS (check all that apply)
State

Female Applicants location at time of application Home Mental Health Hospital Acute Care Hospital In-state In-state

Medicaid applicant county Medicaid recipient number Will apply for Medicaid immediately Medicaid Waiver services recipient Medicaid MCO Enrollee
Referral source: Application date (month, day, year)

Nursing Facility CMHC

Medicaid effective date Other:____________________________ Dept. of Education Dept. of Correction

Other Address:

State Hospital

Community Mental Health Center

Name of parent / guardian Address (number and street, city, state, ZIP code)

Telephone number

(

)

I agree to participate in the mental health hospital screening to determine the need for hospital care and / or waiver services at home and in the community. I authorize the release of information to and among state agencies and their agents on my childs medical condition, and other relevant information necessary to determine appropriate long-term care services and / or in-home services by my physician, hospital, nursing facility, Community Mental Health Center, The Division of Mental Health and Addiction, the Office of Family and Children, other social service or health services providers, and family members. I understand I may revoke this release of information in writing at any time.
Signature of applicant / parent / guardian / responsible person If signature of responsible person, what is the relationship to the applicant? Signature of witness (required if the signature is an X) Signature of Community Mental Health Center or State Hospital Designee Name(s) and address(es) of State Hospital(s) Date (month, day, year) Date (month, day, year) Time

AM PM

1. 2. 3. 4. 5. 6. DISTRIBUTION: Original CMHC Applicant State Hospital File DMHA OMPP