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Division of Disability and Aging Services

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Department of Disabilities, Aging & Independent Living

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Choices for Care (1115 Long-Term Care Medicaid Waiver) Forms

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Choices for Care (1115 Long-Term Care Medicare Waiver)

Form Categories

Flexible Choices Forms

Highest and High Need Forms

Moderate Needs Forms

Flexible Choices Forms

Flexible Choices Allowance (October 2007)

Flexible Choices Budget (July 2006)

Flexible Choices Consent (July 2006)

Flexible Choices Referral (July 2006)

Flexible Choices Self Screen (July 2006)

Flexible Choices Start of Services (February 2007)

Flexible Choices Stop of Services (February 2007)

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Highest and High Needs Forms

Choices for Care Long-Term Care Application Packet

Application for Choices for Care Long Term Medicaid (April 2009)

LTC Medicaid Agreement to Report Change

Information Release Authorization

Long-Term Care Recovery from Estates

Burial Fund Intention Statement

Agreement for Live-in Care (October 2005)

ARIS Employer Handbook (June 2006)

ARIS Employer Agreement (October 2005)

Assistive Devices & Home Modifications (October 2005)

Clinical Assessment (October 2005)

Clinical Certification and/or Highest Paid Provider Change (October 2005)

Clinical Certification (January 2006)

Clinical Eligibility Worksheet (March 2008)

Clinical Eligibility Worksheet - Reassessment (March 2008)

Emergency Contacts & Backup Plan (October 2005)

Employer Certification (October 2005)

ERC Service Plan (July 2007)

ERC Tier Worksheet for CRA (December 2005)

ERC Tier Worksheet for RA (September 2009)

High Needs Wait List Score Sheet (October 2005)

High Needs Waiting List Monthly Follow-up Sheet

Highest Paid Provider Change

Home-Based & ERC Change Report 804 (January 2006)

Home-Based Service Plan CFC 805A (October 2009)

Independent Living Assessment 2009 - Full ILA

Independent Living Assessment 2009 - Health Section Only

Nursing Facility-Hospital-Discharge Notice 804A (January 2006)

Nursing Facility Changes 804B (January 2006)

Personal Care Worksheet (November 2008)

Personal Care Worksheet Instructions (July 2009)

Permission for Release of Information for LTCCCs (April 2006)

Permission for Release of Information for Providers (May 2005)

Resident Assessment

Triggers for High Need Wait List Referral for Clinical Review (February 2006)

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Moderate Needs Forms

Independent Living Assessment 2009 - Intake

Moderate Group Wait List-Form 903

Moderate Needs Application & Request for Reinstatement-Form 900

Moderate Needs Clinical Worksheet-Form 901

Moderate Needs Complete Package Checklist-Form 907

Moderate Needs Service Authorization-Form 904

Moderate Needs Termination-Form 905

Moderate Needs Group Change-Form 906B

Moderate Needs Group Annual Reassessment-Form 906A

Moderate Needs Adult Day Services Wait List Notice

Moderate Needs Homemaker Services Wait List Notice

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