Form 10-007 - Application For Services Form (Page 2 of 3) in pdf

Application for Services

Name:

(Last

(First)

(MI)

(Suffix)

SS#: *

APD Eligibility Determination

7. Collateral/Supporting Information or Source of Information

About Disability

Eligible for APD: _____________ Date: ___/___/_____

(IQ scores, medical records, school records, etc.)

Eligibility Category: _____________________________________

Not eligible Date: ___/___/_____

Reason: ____________________________________

8a. Waiver Eligibility Determination

8b. ICF Eligibility Determination

Eligible for Medicaid Waiver: Date: ___/___/_____

Eligible for ICF: Date: ___/___/_____

Not eligible Date: ___/___/_____

Reason: ____________________________________

By signing this application, I understand and acknowledge that it is my responsibility to keep the Agency informed of any changes in address or

telephone number so that I may be contacted immediately if the Agency has any questions about my application, or, if I am deemed eligible for

services if services have become available. Failure to keep the Agency informed of how I may be contacted may result in my application not

being processed, or if determined eligible for services, my active client status being closed. Further, if my name has been added to the

Medicaid HCBS Waiver Wait list, it will be removed. In the event the Agency is not able to contact me by mail or phone, I authorize the Agency

to contact the following person, who does not live at my address:

ALTERNATE CONTACT:

Name: ________________________________________________________________Phone: _____________________________

Address:_

Relationship to Applicant:__________________________________

E-mail: _________________________________________

10. ALL INFORMATION PROVIDED ABOVE IS COMPLETE AND ACCURATE, TO THE BEST OF MY KNOWLEDGE.

Signature of Applicant: __________________________________________________________________ Date: _______________

Signature of Legal Representative: _________________________________________________________ Date: _______________

For application for government benefits or for making medical decisions

Printed Name of Legal Representative: _______________________________________ Relationship: ___________________________

Signature of Person Assisting the Applicant (if applicable): _______________________________________ Date: _______________

Page 2

FORM TITLE: APPLICATION FOR SERVICES, RULE 65G-4.016

FORM NUMBER: 10-007

YEAR: 2007

Form 10-007 - Application For Services Form Page 2