Address: Amount of money individual can hold on their person at Telephone: any time: Willingness to transfer payeeship to agency: Yes No Agency Name: ________________ (Attach completed Choice, SCAT, & CERT) Contribution to Care amount: Sending Guardianship Guardianship status: eg. (private, self, BGS) How involved is the SC/CM/Natural guardian? Date Established: Support is responsible Name: for securing *Agency needs a copy of information. Address: official guardianship Telephone #: paperwork. Relationship: Health Medical Insurance: Yes No Medicare: Receiving Provider Agency is responsible Carrier: ID#: Group #: for securing supports Medicaid HMO: Private Insurance Carrier: Phone #: and services. Chosen Community HMO: How is medication Annual Medical- Date: administered (whole with Annual Dental- Date: water, crushed in pudding, 72 hr. free from Contagious- Date: etc): Primary care physician: Dentist: How does individual handle Specialty Physician: doctor visits and blood work Mental Health Professionals: (any special instructions): Prescriptions for: Special needs/Equipment (DME): *Discuss Over the Counter Medications: form (provide a copy to Lab Work: individual or family if they do Special diet: not have one already) Allergies: The receiving provider Diagnosis: agency will coordinate the Significant Medical issues- explain: receipt of prescriptions for medication and durable Will any physicians change? If so, provide name and medical equipment (DME) contact info. along with Letters of Medical *Attach list of Medications; include dosage, times of Necessity. administration and treatment purpose. Sending SC/CM is Personal Care Level of support needed for ADL’s: Describe the level of responsible for assistance the individual securing information. Unsupervised Time in home: Yes No needs with each Activity of Unsupervised Time in community: Yes No Daily Living (ADL): (Attach completed Unsupervised Time assessment- *This individual requires 24 hour on-site supervision until Self Medicating?: Yes No (Attach completed Unsupervised Time Assessment for clients currently self medicating) Assessment is completed by agency.
Address: Telephone: Willingness to transfer payeeship to agency: Yes No Agency Name: ________________ (Attach completed Choice, SCAT, & CERT) Contribution to Care amount: Amount of money individual can hold on their person at any time: Guardianship Guardianship status: eg. (private, self, BGS) Date Established: Name: Address: Telephone #: Relationship: How involved is the guardian? *Agency needs a copy of official guardianship paperwork. Sending SC/CM/Natural Support is responsible for securing information. Health Medical Insurance: Yes No Carrier: ID#: Group #: Private Insurance Carrier: Phone #: Chosen Community HMO: Annual Medical- Date: Annual Dental- Date: 72 hr. free from Contagious- Date: Primary care physician: Dentist: Specialty Physician: Mental Health Professionals: Prescriptions for: Special needs/Equipment (DME): Medications: Lab Work: Special diet: Allergies: Diagnosis: Significant Medical issues- explain: Will any physicians change? If so, provide name and contact info. *Attach list of Medications; include dosage, times of administration and treatment purpose. Medicare: Medicaid HMO: How is medication administered (whole with water, crushed in pudding, etc): How does individual handle doctor visits and blood work (any special instructions): *Discuss Over the Counter form (provide a copy to individual or family if they do not have one already) The receiving provider agency will coordinate the receipt of prescriptions for medication and durable medical equipment (DME) along with Letters of Medical Necessity. Receiving Provider Agency is responsible for securing supports and services. Personal Care Level of support needed for ADL’s: Unsupervised Time in home: Yes No Unsupervised Time in community: Yes No (Attach completed Unsupervised Time assessment- Self Medicating?: Yes No (Attach completed Assessment for clients currently self medicating) Describe the level of assistance the individual needs with each Activity of Daily Living (ADL): *This individual requires 24 hour on-site supervision until Unsupervised Time Assessment is completed by agency. Sending SC/CM is responsible for securing information.