Free Form 02AG004E (AG-2-B) Instructions - Oklahoma

Change of Client Status Purpose of form

02AG004I (AG-2-B)

Form 02AG004E (AG-2-B) serves as an annual update to the original Form AG-2-A, Older Americans Act Assessment, Parts I and II. Form AG-2-A, Parts I and II are completed when consumers enter into the Older Americans Act Title III Services for older persons. Instructions Form 02AG004E is used: · as a reassessment form for the year following the completion of Form 02AG002E (AG-2-A, Part I), or the combination of Forms 02AG002E (AG-2-A, Part I) 02AG003E (AG-2-A, Part II). When used for reassessment, Form 02AG004E is used each year, for a maximum of two years, following the first year's completion of Form AG-2-A, Part I. Form 02AG004E will eliminate the need to complete Form 02AG002E, each year. Note: At the discretion of the program representative, Form 02AG004E may be completed by the consumer. In-home service reassessment: Reassessment for any Older Americans Act in-home services recipient includes Form 02AG004E and an updated Form 02AG003E, on them every six months. This process continues through the third year of continuous service. Beginning with the fourth year of continued service, the six-month reassessments can be discontinued only if the Older Americans Act staff person and the consumer documents that due to a prevailing chronic condition, illness, or disease the consumer's condition will not improve. With this documentation and the project director's approval, the reassessments may be replaced with annual visits by the staff, documenting the continued need for the in-home service. Note: Consumers scoring at high risk on the Determine Your Nutritional Health checklist continue to be reassessed every six months regardless of the consumer's chronic condition. · when the status of a consumer changes from the most recent completed Older Americans Act Assessment on file. Staff may use Form 02AG004E to notify the project office of inactive consumers and terminated consumers, for example, death. Routing The completed form is retained at the site office.

Revised 8-13-2003

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