Free Form 02HM001E (AG-2, Part I) - Oklahoma

*02HM001E-001*
OKLAHOMA DEPARTMENT OF HUMAN SERVICES

Uniform Comprehensive Assessment, Part I Intake and Referral
Numbers in parenthesis refer to item numbers in the Oklahoma Long-Term Care Authority (OLTCA) Manual.

Applicant information.
(1) Indicate use of form Intake Screen and prioritization Comprehensive assessment Reassessment Referral out of this office Consumer information. (4) Last name (5) Social Security number (6) Street address First Case number (7) City MI (8) Date of birth Area code (9) Phone Zip (2) Date completed (mo/day/year) (3) Source of referral to this office List name, source, telephone or - readmit

Unique ID number State

Additional sources of information. (10) Last name (12) Street address (13) Relation to consumer: Family, specify Friend Hospital Other, specify Yes No (14) Does the consumer know about this call or assessment interview? First City MI Area code State (11) Phone Zip

(15) (Ask) What problems do you have right now that are causing you difficulty or what do you need assistance with? How long have you had these needs? What services are you receiving?

OKDHS revised 3-15-2007

02HM001E (AG-2, Part I)

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02HM001E (AG-2, Part I)

Uniform Comprehensive Assessment, Part I

(Ask) What program or services are you requesting? (16) Marital status: married single, never married divorced or separated unknown widowed

(17) Consumer's residence. Household composition, for private residence consumers, is: private residence; residential care facility (RCF) or group home; nursing home; or other, specify (18) Consumer lives: alone; with spouse; with children; with relatives; with friends; or other, specify Number in household: (19) Is the assistance of another person required for the consumer to leave home (homebound)? Primary doctor: (20) Primary doctor name Address Other doctor: Other doctor name Address Legal guardian: (21) Name Address Yes No Power of attorney: Area code Yes Phone No Area code Phone Area code Phone Yes No

Relationship to consumer

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OKDHS revised 3-15-2007

Uniform Comprehensive Assessment, Part I Emergency contact (someone outside the home): (22) First emergency contact name Address Second emergency contact name Address (23) Next of kin (nearest relative living in area): Name Address Name Address (24) Consumer financial sources

02HM001E (AG-2, Part I)

Area code

Phone

Relationship to consumer Area code Phone

Relationship to consumer

Area code

Phone

Relationship to consumer Area code Phone

Relationship to consumer Yes $ $ $ $ Amount

Earnings from employment, such as wages, salaries, income from your business Social Security. Include Social Security disability payments, but not SSI Veterans Affairs (VA) benefit such as G.I. Bill and disability payments Disability payments not covered by Social Security, SSI, or VA. Include both government and private disability payments and include Workers' Compensation. Retirement pension from job Money from children on a regular basis Interest or dividend income SSI payments (yellow government checks) Welfare payments: TANF Welfare payments: Food Stamps Other, specify TOTAL (25) Assets, excluding home and automobile

$ $ $ $ $ $ $ $

(Ask) Have you or your spouse transferred, given, deeded, or sold any property in the Yes No past five years? OKDHS revised 3-15-2007 Page 3 of 5

02HM001E (AG-2, Part I)

Uniform Comprehensive Assessment, Part I

Do you have any checking accounts? Amount: $ Total asset: $

Yes

No Veteran Neither Spouse

(26) Are you a veteran or ever been a spouse of a veteran? (27) Health insurance. Medicare - Part A Medicare - Part B SoonerCare (Medicaid) VA Health maintenance organization (HMO) Indian Health Services Other health insurance Don't know (28) Additional information. (29) What type of work did/do you do? What grade did you complete in school? (30) Gender: Female Male

Yes Yes Yes Yes Yes Yes Yes Yes

No No No No No No specify:

Medicare number: Medicaid number:

(31) Race or ethnic background. Read all categories before selecting answer. Do you consider yourself: White Black/African American Native American or Alaskan Hispanic Asian or Pacific Islander Other, specify:

(32) Are you a U.S. citizen or legal resident? Yes No If no, country of origin: Alien registration card number: English (33) Consumer's primary language: Does the consumer: speak English? understand English? Is consumer: deaf blind mute Spanish Other, specify: Yes No Yes No

If so, describe consumer's method of communication: (34) Referrals: Referral date mo/day/year Services referred for Agency referred to Contact name

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OKDHS revised 3-15-2007

Uniform Comprehensive Assessment, Part I (35) Directions to consumer's location:

02HM001E (AG-2, Part I)

Completed by, print name

Agency

Area code

Phone

Additional comments and information.
The following actions were taken in response to the consumer's inquiry regarding in-home service provision: referral to Indigent Drug Program referral to Oklahoma Areawide Services Information System (OASIS) referral to Personal Care Program referral to the ADvantage Program advised of the availability of nursing facility care no action taken. Client does not want to apply for the ADvantage or Personal Care programs referral to Adult Protective Services provided information regarding other OKDHS programs referral to Area Agency on Aging (AAA) other referral, specify: Notes:

Signature of person completing form Date application received by OKDHS nurse:

Date

OKDHS revised 3-15-2007

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