Intake
§ We need Consumers personal history- including medical status, family emergency contact information and other pertinent information.
§ We need copy of all Medicaid and Medicare and any other 3rd party insurance cards for files.
§ We need legal guardianship form or responsible party form.
§ We need consent to medical treatment form.
§ We need a record of current medications including dosage times.
§ We need a service plan and service agreement (on same form), and notice of privacy act (HIPPA forms)
§ We need a current (within 12 months) health assessment signed by a health physician and also T.B. Screen.
§ We need the consumer rights form.
§ We need the D.M.A.-6, P.A. forms, and current ISP.
§ We need a Changing Lives Assessment Form.
Intake Process
§ Upon receiving a referral CLDC administration will complete an assessment.
§ After initial assessment and determination is made to accept the Consumer, CLDC will set up an intake meeting with the family and all of the forms needed in the file will be completed at this time.
§ CLDC shall request the family to bring:
1. Medical history and insurance cards with all doctor and dentist phone numbers and addresses
2. Current list of medications
3. Legal guardianship forms
4. Current photos of Consumers
5. State ID
6. T.B. Screen
7. Current physical
§ Upon receiving a referral CLDC will make contact with the referral source/ family within 2 business days.
