Free Form 02AS003E (ADS-RA-1) Instructions - Oklahoma

Adult Day Services Referral/Application Purpose of form Form 02AS003E is used to: · · · document an applicant's request for adult day services; determine financial eligibility or ineligibility; and inform the applicant of his or her responsibilities. Instructions

02AS003I (ADS-RA-1)

A. Participant information: Enter applicant's identifying information, name of county where residing, and OKDHS case number, if applicant is receiving services. B. Authorized representative information: Enter the information of the applicant's authorized representative. C. Income documentation: Record the applicant's gross monthly income from all sources, and record the documentation used to verify each source of income. D. Income computation: This section is completed by the county office only. Applicants already receiving OKDHS assistance are predetermined eligible.

Adult Day Services participant and authorized representative responsibilities: The applicant reads, signs, and dates page two to indicate that his
or her responsibilities have been explained. By signing page two, the applicant indicates that he or she understands and agrees to his or her responsibilities. If the applicant cannot read or write, the authorized representative may sign the application. Routing The adult day services center mails or delivers the form, with the income documentation attached, to the county office nearest to where the applicant lives. A copy is given to the applicant. If the adult day services center generated the application, a copy is maintained by the center. The original form is filed in the participant's record at the county office.

Issued 11-1-2006

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