Free 46018.FH11 - Indiana

TRANSMITTAL FOR MEDICAID LEVEL OF CARE ELIGIBILITY
State Form 46018 (R4 / 8-05) / HCBS 0007

Aged or Disabled
Name Address (number and street) City, state, ZIP code Name of guardian Address (number and street) City, state, ZIP code Name of case manager requesting L.O.C.

Autism

MFC

TBI

AL

AFC

DD

Sup Srv

ICF / MR

Medicaid number

BDDS
Name of agency Address (number and street) City, state, ZIP code Telephone number

AAA

Waiver Only

(
Purpose of Level of Care Determination

)

Initial

Annual Redetermination

Other (specify) ______________________________________

Waiver Displacement Status

Diversion
Name of facility

Deinstitutionalization From: Nursing Facility ICF / MR

Address of facility (number and street, city, state and ZIP code)

Date (month, day, year)

NURSING FACILITY RESIDENTS ONLY

OBRA 1987 Residential Alternative Offered: The diagnostic information is a current and valid reflection of the individual.
Signature of reviewer

Not Applicable Residential Choice (attach form)

STATE OFFICE OF MEDICAID POLICY AND PLANNING USE ONLY

This application cannot be finalized due to:
Comments

Missing Forms

Missing Data

Clarification needed

Approved for Level of Care Hospital NF / AL
Signature and title

Disapproved for Level of Care - SEE ATTACHMENT NF / I NF / S NF / TBI Hospital NF / AL ICF / MR NF / AFC NF / I NF / S NF / TBI

ICF / MR NF / AFC

Date (month, day, year)