Free Community Long Term Care Services Referral to Income Maintenance Worker - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Long Term Care F-21051 (08/2008)

STATE OF WISCONSIN

COMMUNITY LONG TERM CARE SERVICES REFERRAL TO INCOME MAINTENANCE WORKER (IMW)
This is a voluntary form. Failure to complete this form or its equivalent may delay your referral. The information contained in this form must be on file in some format. Name ­ Applicant (Last, First, MI) Social Security Number Medicaid No. if Different Street Address City, State, Zip Code Marital Status Single Divorced Living Arrangement Own Home/Apartment Substitute Care Facility Other--specify: Date of Birth Telephone Number

Married Widowed

Nursing Home--relocating to own home/apt Nursing Home--relocating to Substitute Care Facility Telephone Number

Name ­ Contact Person

Relationship to Applicant (e.g., guardian of person, guardian of finances, POA, Rep. payee, authorized representative, son) Street Address City, State, Zip Code Date of Initial Request for Community Waiver: Is individual a "transfer" to or from a Family Care County? (If yes, prioritize for continuous MA): Anticipated Waiver Start Date: Date of Referral from Care Manager/Support & Service Coordinator (SSC)/Resource Center to IM Worker: Name ­ Care Manager/Support and Service Coordinator Type of Long Term Care Program Target Group Eligibility (check one) CIP 1A CIP 1B CIP II COP-W COR PACE Partnership CLTS PACE/Partnership Agencies ­ Level of Care (LOC) Check One Intermediate Care Facility (ICF) Intensive Skilled Nursing (ISN) Telephone Number Community Waiver Functional Eligibility? Yes No Family Care - Specify LOC

Family Care Brain Injury Waiver Skilled Nursing Facility (SNF)

Special Housing Amount in Substitute Care ­ Rent only from Room and Board costs $ Group B 1 - Monthly Out of Pocket Remedial Expenses Out of pocket expenses only (Do not include health insurance premiums in this figure. IM Worker collects this information separately.)
2 Group C - Monthly Medical Remedial Expenses

a. Out of pocket 3 b. COP services (except for COP funded room/board) c. Waiver services d. Total

$ $ $ $

e. Medicaid Card services:

$

Plan for Processing Application (check one) Care Manager/SSC will arrange appointment with IMW Other--specify:

IMW will arrange own appointment

1 2

IMW enters Group B medical/remedial expenses on AFME CARES Screen IMW enters Group C medical/remedial and Medicaid card services on ANCW CARES Screen 3 Do not include health insurance premiums in this figure. IM Worker collects this information separately.