Free HSRS Long-Term Support Module - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Enterprise Services F-22018 (Rev. 12/2008)

HSRS LONG-TERM SUPPORT MODULE
MODULE TYPE A
REGISTRATION - Screen L1 N / U / I / E (Module Key: 1 Worker ID 2a Last Name 4 Client ID 5 Birthdate (mm/dd/yyyy) 6 Sex ) 2b First Name 7a Hispanic/Latino 2c Middle Name

STATE OF WISCONSIN SOS Desk (608) 266-9198 Completion of this form meets the requirements of the State / County contract specified under the Wisconsin Statutes. S. 46.031(2g). P.L. 97-35; Federal Regulations: 42 CFR 441

2d Suffix

3 MA Number (10 digits) OR SSN (9 digits)

7b Race (Circle up to 5) 8 Client Characteristics A=Asian B=Black or African American F Yes W=White I=American Indian or Alaska Native M No P=Native Hawaiian or Pacific Islander 9 Level of 10 Marital 11 Living Arrangement 12 Natural Support 13 Type of Movement / Prior Location (Check 1) Care Status Source (Optional for COP assessment, plan, applicant register) Prior Current People N=Relocated from general nursing home D=Diverted from entering any type of institution F=Relocated from ICF / MR facility B=Relocated from brain injury rehab unit 17 MA Waiver Financial Eligibility Type 14 Special 15 County of Fiscal 16 Court Ordered 18 Indicator for Waiver Mandate (Optional for COP assessment, A=Categorically eligible Project Status Responsibility Placement plan, applicant register) B=Categorically financially eligible - special income limit A=MA Waiver eligible Y=Yes C=Medically needy B=Not MA Waiver eligible N=No D=COP eligible C=MA Waiver eligible but exempt *Provider Number Required for SPCs: SERVICES - Screen L2 U/I (Module Key: ) 102 Adult day care 19 Episode End Date 20 Closing Reason CIP1A and CLTS-W Only 202/01/02 Adult family home 21 Slot Number 22 Start Date 23 End Date 506 CBRF 604 Supportive and service coordination (CIP1A, 1B, BIW, CLTS-W, COR) 711 Residential care apt. complex STATE USE ONLY STATE USE ONLY 896 ICF-MR/NH residents PGM No 24 SPC/Subprogram 25 Target 26 LTS 27 Funding 28 SPC Start Date 29 SPC End Date 30 Provider Number 31 SPC Review Date * Required for some SPCs mm yyyy Group Code Source

OPTIONAL DATA - Screen 18 Street Address Case Review Date Diagnosis

NOTE: Street address, city, state, zip code and county are required for CIP 1A, 1B, BIW and CLTS-W. City State Zip Code County Family ID Local Data

Telephone

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Shaded areas are optional.

DEPARTMENT OF HEALTH SERVICES Division of Enterprise Services F-22018 (Rev. 12/2008) UNITS / COSTS - Screen L3 U / I PGM No 32 Units 33 Costs (Module Key: 34 Delivery Date mm yyyy )

STATE OF WISCONSIN 2

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $