Resource Item Eleven Resource Verification Complete Worker ID: Resource Item Twelve Resource Verification Complete Worker ID: LONG TERM CARE/OPTIONAL STATE SUPPLEMENTATION Type of Care Nursing Home In-Home Care (Waiver) PACE General Hospital Optional State Supplementation (OSS)/Community Residential Care Facility (CRCF) Date of Level of Care Hospital/Nursing Facility/ Entry/ OSS Slot (For Nursing Home and Waiver Program/CRCF Enrollment Date Care only) Date Eff. Date: Eff. Date: Eff. Date: Must Meet 30 Consecutive Day 30 Consecutive Days Met Phoenix Checked Phoenix Updated Notes: Look-Back Transfer of Penalty Period Assets Worker ID: Status: Start: End: Notes: Spousal Allocation Dependent Health Home Maintenance Allowance Relative Insurance Allocation Premium Deduction Amount: End: Notes: Income Trust Trust Document Effective Date: Account Approved Designated Notes: Account Funded Complete The Following If A VR Disability Determination Is Needed
Resource Item Eleven Resource Verification Complete Worker ID: Resource Item Twelve Resource Verification Complete Worker ID: LONG TERM CARE/OPTIONAL STATE SUPPLEMENTATION Type of Care Nursing Home In-Home Care (Waiver) PACE General Hospital Optional State Supplementation (OSS)/Community Residential Care Facility (CRCF) Hospital/Nursing Facility/ Waiver Program/CRCF Date of Entry/ Enrollment Date Level of Care (For Nursing Home and Care only) OSS Slot Date Eff. Date: Eff. Date: Eff. Date: Must Meet 30 Consecutive Day 30 Consecutive Days Met Phoenix Checked Phoenix Updated Notes: Look-Back Transfer of Assets Penalty Period Worker ID: Status: Start: End: Notes: Spousal Allocation Dependent Relative Allocation Health Insurance Premium Deduction Home Maintenance Allowance Amount: End: Notes: Income Trust Trust Document Approved Effective Date: Account Designated Notes: Account Funded Complete The Following If A VR Disability Determination Is Needed