Free Form 02AS002E (ADS-MR-1) - Oklahoma

*02AS002E-001*
OKLAHOMA DEPARTMENT OF HUMAN SERVICES Aging Services Division

Adult Day Services Monthly Report
Month of , 20

Name of center Total number of new Oklahoma Department of Human Services (OKDHS) participants approved: Name Case number

[Multiple entries can be made]

Total number of OKDHS applications pending: Name [Multiple entries can be made] Social Security or case number [Multiple entries can be made] Date referred

Total number of new ADvantage participants approved: Name Case number

[Multiple entries can be made]

Total number of ADvantage applications pending: Name [Multiple entries can be made] Social Security or case number [Multiple entries can be made] Date referred

Total number of Developmental Disabilities Services Division (DDSD) participants approved:

Revised 12-1-2005

02AS002E (ADS-MR-1)

Page 1 of 2

02AS002E (ADS-MR-1) Name

Adult Day Services Monthly Report Case number

[Multiple entries can be made]

Total number of DDSD applications pending: Name [Multiple entries can be made] Social Security or case number [Multiple entries can be made] Date referred

Total number of OKDHS participants terminated: Reason codes: A - Client decision B - DDSD decision C - Caretaker decision

D - OKDHS decision E - ADvantage decision F - Facility decision Reason

H - Nursing home placement X - Client death

Name [Multiple entries can be made]

Name [Multiple entries can be made]

Reason

Total OKDHS participants younger than age 60 enrolled at this time: Total participants enrolled in the ADvantage Waiver Program at this time: Total participants enrolled in the DDSD Waiver Program at this time: Total participants served as private pay this month: Total OKDHS claims filed this month: Do not include pending claims that do not have written approval. Signature of director Date

Page 2 of 2

Revised 12-1-2005