Alwp Client Inquiry Pre-Screen Form
ADVERTISEMENT
1
2Please FAX or Email to:
Bill Mathis
Fax # (619) 448-8078
Phone (888) 681-1559
ALW Website:
or (619)-757-1114
ALWP CLIENT INQUIRY PRE-SCREEN FORM
Name of Medi-Cal Beneficiary:________________________________________________
Date:_____________________
Name of Person completing form / Relationship:______________________________________________________
Name of Conservator/Power of Attorney :____________________________________________________________
Phone: (
) _______________________
email: _____________________________________________________
If the MediCal Beneficiary is not self responsible for Health Care Decisions, the Legal Conservator or Durable Power of Attorney
(DPOA) for HealthCare must submit proof of documentation prior to consideration for enrollment into the ALW Program.
Name of Assisted Living Facility you are interested in:_________________________________________________
Beneficiary's Current Residence / Name of facility: ___________________________________________________
Address:_______________________________________________________________________________________
□
□
□
Rollover
Home
Skilled Nursing Facility (SNF)
(already residing at participating facility)
MUST HAVE THE FOLLOWING BEFORE CONTINUING
Medi-Cal Number: __________________________Card Issue Date:______________
(Attach copy of Medi-Cal Card)
M
F
Date of Birth:____________________
Age: _______________
Gender:
Current Total Monthly Income: $___________________
Monthly SSI Income: $_______________________
( Must receive less than $1420. monthly with no Medi-Cal share of cost to apply )
Beneficiary Payee Name:__________________________________________________ Ph# (
)_____________________________
□
□
ARE YOU RECEIVING MEDICARE BENEFITS?
YES
NO
IF YOU ARE STAYING IN AN ACUTE HOSPITAL OR SKILLED NURSING FACILITY AND
Date:____________________________
MEDICARE IS BEING BILLED, ON WHAT DATE WILL MEDI-CAL BILLING START?
IF RESIDING IN A SKILLED NURSING FACILITY,
WE REQUIRE A COPY OF THE APPROVED MEDI-CAL TREATMENT AUTHORIZATION REQUEST (TAR)
Cognitive Issues and Diabetes
□
□
□
□
Cognitive Issues:
Confused
Dementia
Alzheimer's
Wanders
□
□
□
Diabetes:
Injections
Self Injects
Blood Sugar Checks Need Assist
□
□
Does this client have any behavioral Issues? (HISTORY OF VIOLENCE ETC…)
YES
NO
Mental Health Issues: □ YES
□ NO
□ Bi-polar
□ Schizophrenia
□ Manic Depression
If you answer Yes to any of the questions below, then STOP. These medical conditions must be cleared prior to
enrollment consideration
□
□
Is this client on Hospice?
YES
NO
□
□
Does the client have any stage 3 or 4 pressure sores?
YES
NO
□
□
Does the client have a Nasogastric-Tube or dependent on a ventilator?
YES
NO
□
□
Is the client receiving Chemotherapy? (Ok if able to receive outside of facility)
YES
NO
□
□
Is the client receiving Wound-Vac Therapy?
YES
NO
□
□
Does the client need to be restrained or has been?
YES
NO
□
□
Does the client have Active Communicable Tuberculosis?
YES
NO
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form 8850 - Pre-screening Notice And Certification Request For The Work Opportunity Credit
Financial
Form 8850 - Pre-screening Notice And Certification Request For The Work Opportunity Credit
Financial
Form 8850 (rev. January 2012) - Pre-screening Notice And Certification Request For The Work Opportunity Credit
Financial
Form 8850 - Pre-screening Notice And Certification Request For The Work Opportunity Credit - 2009
Financial
Form 8850 - Pre-screening Notice And Certification Request For The Work Opportunity And Welfare-to-work Credits
Financial
Form 8850 - Pre-screening Notice And Certification Request For The Work Opportunity Credit - 2016
Legal
Related Categories
Parent category: Medical