Medicaid Agency Waiver printable pdf download

ALABAMA MEDICAID AGENCY

WAIVER and PACE MEDICAL / SLOT CONFIRMATION FORM

Client’s Name ______________________________________________________________

Client’s Address ____________________________________________________________

__________________________________________________________________________

Social Security Number ______________________________________________________

Operating Agency __________________________________________________________

Name of Waiver ____________________________________________________________

Waiver Slot Available Yes ____ No ____ Date ___________________________________

Level of Care Approved Yes ____ No ____ Date _______________________________

Disability Determination Required *Yes ____ No ____ Onset Disability _____________

Waiver Transitional Medicaid Transitioning from Nursing Facility? Yes ____ No ______

Date of Discharge from Nursing Facility ________________________________________

Start Date of Waiver Services _________________________________________________

Name/Address of Nursing Facility ____________________________________________

_________________________________________________________________________

Transferring from Another Waiver? Yes ____ No ____ Date of Transfer ____________

Name of Waiver Transferring from ____________________________________________

*******************************

PACE SERVICES

Transitioning from Nursing Facility to PACE Program? Yes ________ No __________

Name/Address of Nursing Facility transitioning from: _____________________________

_________________________________________________________________________

Date of Discharge from Nursing Facility: _______________________________________

Name of PACE Provider: ___________________________________________________

Start Date of PACE Services: ________________________________________________

Transitioning from Waiver to PACE Program? Yes ____________ No ______________

Name of Waiver transitioning from: ___________________________________________

Date of Discharge from Waiver: ______________________________________________

Name of PACE Provider: ___________________________________________________

Medicaid Agency Waiver