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*THIS STATE AGENCY IS REQUIRING DISCLOSURE OF YOUR SOCIAL
SECURITY NUMBER PER IC 4-1-8-1 THE INFORMATION OBTAINED
ON THIS FORM IS CONFIDENTIAL UNDER STATE AND FEDERAL
REGULATIONS THIS INFORMATION WILL NOT BE RELEASED
EXCEPT AS PERMITTED OR REQUIRED BY LAW OR WITH THE
CONSENT OF THE APPLICANT.
APPLICATION FOR LONG-TERM CARE SERVICES
State Form 45943 (R9 I 7-06) I BAJS 0018
PLEASE COMPLETE BOTH SIDES OF THIS FORM.
Application is for (check one):
PreAdmission Screening (IPAS) I PreAdmission Screening and Resident Review (PASRR)
In-Home Services
If In-Home Services, check all that apply
C.H.O.I.C.E.
AL Waiver
TBI Waiver
SECTION I - GENERAL INFORMATION
Federal law provides criminal penalties, including a fine and/or imprisonment for up to 5 years, for concealing a material fact
or making a materially false statement. (See 18 U.S.C. 1001)
1. NAME OF APPLICANT
(Last, First, Middle Name)
2. OTHER NAMES USED
3. GENDER
4. SOCIAL SECURITY NUMBER
5. DATE OF BIRTH
(mm/dd/yyyy)
6D. COUNTY
6F. E-MAIL ADDRESS
6A. CITY
6C. ZIP
6. PERMANENT ADDRESS
(Street)
6E. HOME TELEPHONE NUMBER
(Include area code)
6B. STATE
8. NAME, ADDRESS AND RELATIONSHIP OF NEXT OF KIN
MALE
FEMALE
MARRIED
NEVER MARRIED
SEPARATED
WIDOWED
DIVORCED
UNKNOWN
7. CURRENT MARITAL STATUS
(Select one)
SECTION II - MEDICAID STATUS
CHECK ALL THAT APPLY:
a. MEDICAID APPLICANT COUNTY NUMBER
:
b. MEDICAID RECIPIENT NUMBER:
c. NON-MEDICAID / PRIVATE-PAY FOR AT LEAST 6 MONTHS AFTER ADMISSION
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.
Every person applying for admission to a nursing facility 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
/PAS /Information Sheet
for program details.
SECTION III - PREADMISSION SCREENING NOTIFICATION