Apd - Application For Services Form (Page 4 of 6) in pdf

Application for Services

15. 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: _________________________________________

16. 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: ______________

17. Referrals

(to be filled out by APD Staff):

Date

Contact

Address/Telephone #

I have received a copy of:

The Bill of Rights of Persons who are Developmentally Disabled, section 393.13, Florida Statutes.

Family Care Council Brochure

Serving Floridians with Developmental Disabilities - brochure

Agency for Persons with Disabilities Guide to Administrative Hearings- brochure

HIPAA Notice of Privacy Practice

YOU CAN APPLY TO REGISTER TO VOTE HERE

If you are not registered to vote where you live now, would you like to register to vote here today? Check YES if you

would like to apply to register to vote or update your voter registration information. If you check the NO box or do not

check a box, you will be considered to have decided not to apply to register to vote or update your voter registration

information. Checking YES, NO, or leaving this question blank will not affect your receipt of benefits.

YES

NOTICE OF RIGHTS

Help: If you would like help in filling out your voter registration application, we will help you. The decision whether to seek

or accept help is yours. You may fill out the voter registration application in private.

Benefits: If you are applying for public assistance from this agency, applying to register, or declining to register to vote

will not affect the amount of assistance you will be provided by this agency.

Updated January 21, 2016

Apd - Application For Services Form Page 4