Free Community Relocation Initiative Initial Information and Funding Estimate - Wisconsin


File Size: 102.9 kB
Pages: 1
Date: July 30, 2008
File Format: PDF
State: Wisconsin
Category: Health Care
Author: DHS
Word Count: 336 Words, 2,204 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://dhs.wisconsin.gov/forms1/f2/f22678.pdf

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DEPARTMENT OF HEALTH SERVICES Division of Long Term Care F-22678 (07/2008)

COMMUNITY RELOCATION INITIATIVE INITIAL INFORMATION AND FUNDING ESTIMATE
Completion of this form is voluntary. If not completed, the request cannot be processed. The personally identifiable information is being collected to process potential program eligibility. Completed forms will only be accessed by staff processing the request.

Name ­ Applicant Date of Birth Medicaid Number

County Applying Name of Nursing Home Is the Nursing Home Closing or Downsizing? Yes No

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Date of Planned Relocation/Discharge

Date of Admission to Nursing Home

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Document why this person's nursing home stay is expected to be long term

Proposed New Living Arrangement This cost includes the following estimated daily amounts: Supportive Home Care CBRF Service Per diem Adult Day Care One time waiver costs: Adaptive Aids Care management

Estimate of the person's daily waiver cost (Do not include room and board, cost share or one time waiver costs.) Transportation Other

Waiver Allowable Home Modifications

Room and board costs in substitute care setting

Estimate of the daily Medicaid card services person will need (hours/day; times/week): MA Personal Care Home Health (RN / Therapies) Other Known, e.g., Transportation., DME, DMS

Will this person receive SSI upon return to the community? Will this person access the SSI Exceptional Expense (SSI-E) benefit? Will one time funding be needed for start-up costs (clothing, groceries) not covered by CIP II SPC 106.03 or 604.04? Explain cost and items

Yes Yes Yes

No No No

Amount of person's income: SIGNATURE ­ Care Manager Telephone Number Fax Number Name ­ Care Manager (Print) E-Mail Address Date Signed

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Fax completed form to Bureau of Long-Term Support/Community Relocation Initiative at 608-267-2913 For Bureau of Long-Term Support use

Estimate not able to be approved:
Estimate approved by BLTS on:

no Medicaid data available

BLTS will hold as pending

Estimate approved. Develop and submit waiver application packet to TMG for FINAL approval of CRI plan and funding.
Total Estimate Amount Approved: Estimate approval faxed to county on:

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