Application For Long Term Care Services

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*THIS STATE AGENCY IS REQUIRING DISCLOSURE OF YOUR

APPLICATION FOR LONG-TERM CARE SERVICES

SOCIAL SECURITY NUMBER PER IC 4-1-8-1. THE INFORMATION

OBTAINED ON THIS FORM IS CONFIDENTIAL UNDER STATE AND

State Form 45943 (R10 / 5-15)

FEDERAL REGULATIONS. THIS INFORMATION WILL NOT BE

RELEASED EXCEPT AS PERMITTED OR REQUIRED BY LAW OR

WITH THE CONSENT OF THE APPLICANT.

PLEASE COMPLETE BOTH SIDES OF THIS FORM.

Application is for (check one):

Initialed by

Home and Community Based Services (HCBS)

Program of All-Inclusive Care for the Elderly (PACE)

Indiana's PreAdmission Screening (IPAS) / PreAdmission Screening and Resident Review (PASRR)

If In-Home Services, check all that apply:

A & D Waiver

MFP

C.H.O.I.C.E.

S.S.B.G.

Title III In-Home Services

TBI Waiver

SECTION I - To be completed by the applicant, guardian, or responsible person.

Name of applicant

Telephone number

Social Security number *

(

)

Home address (number and street, apartment number, rural route number, city, state, and ZIP code)

State of residence prior to NF placement

Reason why out-of-state resident is requesting admission to an Indiana nursing facility

Indiana

Other ___________________________________

No bed available in home state

Date of birth (month, day, year)

Sex

Family is moving to or resides in Indiana, etc.

Age

Male

Female

Other ___________________________________________________

Marital status:

Medicaid status (check all that apply)

State: __________________________

Married

Single

Divorced

Separated

Widowed

a. Medicaid applicant county number: ________________________

Applicant's location at time of application:

b. Medicaid recipient number: ______________________________

c. Will apply for Medicaid

At admission or within

a. Home

b. Hospital

c. CMHC

d. Nursing Facility

In-state

120 days

Out-of-state

e. Other ________________________________________________

d. Non-Medicaid / Private-pay for at least 6 months after admission

e. Medicaid Waiver Services recipient

Yes

f. Medicaid MCO Enrollee

Medicaid effective date: __________

Address: _____________________________________________

Telephone number

Name of relative or contact person / address (number and street, city, state, and ZIP code)

(

)

Telephone number

Name of physician / address (number and street, city, state, and ZIP code)

(

)

VERIFICATION

I, _________________________________________________, hereby verify under penalty of perjury that I am a United States citizen or qualified alien

(Insert name.)

(as defined under 8 USC 1641). I also verify that I am a resident of the State of Indiana.

Signature of applicant or responsible person

Date (month, day, year)

PREADMISSION SCREENING NOTIFICATION

Every person applying for admission to a nursing facility in Indiana must be assessed by the PreAdmission Screening Program (PAS) to determine the

person's need for care in a nursing facility. Failure to participate in the PreAdmission Screening Program will result in the applicant's ineligibility for

Medicaid reimbursement in any nursing facility for up to one (1) year from date of admission. NOTE: See IPAS Information Sheet for program details.

I AGREE to participate in the PreAdmission Screening Program to determine my need for care in a nursing facility and/or home and

community-based services.

I AUTHORIZE THE RELEASE OF INFORMATION to and among state agencies and their agents on my medical condition and other relevant

information necessary to determine appropriate long-term care services and/or In-Home Services, by my physician, hospital, nursing facility,

Community Mental Health Center, Division of Mental Health and Addiction, Office of Family Resources, other social service or health services

providers, and family members. I understand I may revoke this release of information in writing at any time.

I DO NOT AGREE to participate in the PreAdmission Screening Program and I understand that I will not be eligible for Medicaid reimbursement in

any nursing facility for up to one (1) year from date of admission.

Signature of applicant or responsible person

Time

Date (month, day, year)