Chapter LTCCAP LTCCAP FACE SHEET INSTRUCTIONS Replace the NF by djmbenga

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									Chapter 1 –20 – LTCCAP                                                        3/19/2007




                         LTCCAP FACE SHEET INSTRUCTIONS



Replace the NF OAF face sheet with the LTCCAP modified orange color coded face sheet
received from the LTCCAP contractor.

LTCCAP face sheet instructions are as follows:

Referral by Agency Name – List the name of the agency making the referral, which may be
the LTCCAP provider.

Contact Person - This will be the person designated by the LTCCAP Contractor Agency.

Telephone Number - The telephone number of the contact person at the LTCCAP
Contractor Agency.

Other assists needed for assessment - All special needs which the applicant may have
that need to be considered for the assessment should be listed here.

MA-51 Attached - This must always be attached and checked "yes" in the box.

Class of Assessment - Nursing Facility is the only class of assessment and this box must
be checked.

LTCCAP Waiver - Both MA-51 and Assessment Form boxes must be checked.

Everything above the double bold line is to be completed by the LTCCAP contractor while
everything below the double bold line is to be completed by the OPTIONS Assessment Unit.
Chapter 1 –20 – LTCCAP                                                                   3/19/2007
                                       OPTIONS ASSESSMENT FORM
                         (LONG TERM CARE CAPITATED ASSISTANCE PROGRAM)



Consumer Name:                                                      Social Security Number:


Address:                                                            Recipient Number:


                                                                    Birthdate:


                                                                    Telephone Number:


Referred by Agency Name:                                            Language Assistance Needed for Assess?       Yes   No


Contact Person:                                                     Other Assists Needed for Assessment:


Telephone Number:


Emergency Contact Name:


Telephone Number:

                                                                                                     MA-51 Attached    Yes




Assessed by:                                                        Date:


Location of Interview:


Present for Interview:   Consumer       Sig. Other     Other:


        Names:




Class of Assessment Completed:      Nursing Facility
                                                                |                                                 |
                                                                |    LTCCAP                                       |
                                                                |                                                 |
                                                                |           MA-51                                 |
                                                                |           Assessment Form                       |
                                                                |                                                 |

								
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