Free SSI-E Natural Residential Setting Application Checklist - Wisconsin


File Size: 17.7 kB
Pages: 1
Date: August 18, 2008
File Format: PDF
State: Wisconsin
Category: Health Care
Author: DHS
Word Count: 266 Words, 1,783 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://dhs.wisconsin.gov/forms1/f2/f20812.pdf

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DEPARTMENT OF HEALTH SERVICES Division of Long Term Care F-20812 (Rev. 08/2008)

STATE OF WISCONSIN Completion of this form is required by Section 49.77(3s), Wis. Stats.

SSI-E NATURAL RESIDENTIAL SETTING APPLICATION CHECKLIST
Name - SSI Recipient (Last, First, MI) County Agency

A. FINANCIAL ELIGIBILITY YES NO
1.

POLICY REFERENCE Currently receives SSI. Page: 11

B. LIVING ARRANGEMENT 2. 3. 4. 5. 6. 7. 8. 9. C. ASSESSMENT 10. Used COP or other functional assessment process. 11. Shows the need for 40 hours or more per month of primary long-term support services (SHC, DLST, CSP). 12. If person lives with a spouse or is a minor child living with parent(s), then assessment ONLY counts needs which cannot be met because: (a) the parent or spouse is out of the home for employment; or (b) the spouse is physically or mentally not capable of providing care. D. FORMS F-20818 Certification for SSI-E completed; including 14. Correct effective date; and 15. Social Security number correctly and legibly written. 16. F-20817/F-20817A Assessment Worksheet completed and on file at county agency. 13. Page: Page: 16 17 Page: Page: 14 14 Lives in house or apartment. Lives alone or with spouse only. If "NO" Pays proportionate share of household expenses while living with others. Neighborhood includes non-elderly and nondisabled people; and Neighborhood provides access to services and community resources; and Neighborhood offers regular and informal opportunities for social integration. Qualifies because resides in a qualifying substitute care facility; and Qualifies because not part of or on the grounds of an institution. Page: 12

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Name ­ Case Worker

Today's Date

Telephone Number

Keep in Agency Case Record