Long Term Care Templates

This form is used for submitting a referral for long-term services and supports in the state of New Jersey. It provides instructions on how to fill out the form and where to submit it.

This form is used for notifying the state of New Jersey about the admission or termination of a Medicaid beneficiary in a long-term care facility.

This form is used for the Money Follows the Person Eligibility Screening Tool in New Jersey. It helps determine eligibility for the program.

This form is used for the re-evaluation of long-term care needs in the state of New Jersey. It helps determine the eligibility and level of care needed for individuals receiving long-term care services.

This Form is used for long term care re-evaluation in New Jersey.

This form is used for recording the supplementation of a resident's room in a long-term care facility in New Jersey.

This Form is used for optional designation for determining resident charges related to long-term care in Saskatchewan, Canada.

This form is used for nominating and giving consent for long-term care residents in Saskatchewan, Canada.

This form is used for requesting deemed continued eligibility in New Jersey for CP-3 Pace.

This Form is used for voluntary withdrawal from the MLTSS program in New Jersey. It allows individuals to request to leave the program voluntarily.

This document is the consent form for participants in the Mi Via Self-directed Waiver program in New Mexico. It outlines their responsibilities and understanding of the annual requirements.

This form is used for creating a legally binding agreement between a home care provider and a client in New York. It outlines the services to be provided, payment terms, and responsibilities of both parties.

This form is used for designating assets for Long-Term Care Partnership (LTCP) in Washington state.

This Form is used for the Admissions Review Team Checklist for Admission to an ICF/IID or SONF at a Residential Habilitation Center (RHC) in Washington.

This form is used for pre-admission screening and resident review in Washington state. It is required for individuals seeking long-term care services to determine their eligibility and level of care needed.

This Form is used for conducting quality improvement visits and assessments of Adult Family Homes (AFHs) in the state of Washington. It helps the Department of Social and Health Services (DSHS) in ensuring the quality and safety of care provided to residents in AFHs.

This form is used for applying for registration with the Community Residential Care Centers (CCRCs) in Washington state.

This document provides information about your rights and responsibilities when receiving services from the Aging and Long-Term Support Administration and Developmental Disabilities Administration in Washington.

This form is used for the intake screening process at an Adult Day Center in Pennsylvania. It helps evaluate the eligibility and needs of individuals seeking care at the center.

This document is for individuals who want to apply for a license as a nursing home administrator in Rhode Island.

This document provides information about the staffing requirements for nursing homes in Rhode Island. It outlines the guidelines and regulations for hiring and maintaining a skilled and sufficient staff to ensure quality care for residents.

This document is used to apply for registration for continuing care in the state of Rhode Island.

This form is used to apply for assistance for elderly individuals in South Carolina.

This form is used for reporting the history of a long-term care facility in Texas. It helps track any previous incidents or violations that may have occurred.

This form is used for submitting an original application to become an online course provider for long-term care training in the state of Texas.

This form is used to inform individuals receiving services from the Aging and Long-Term Support Administration and Developmental Disabilities Administration in Washington about their rights and responsibilities. It is available in Somali language.

This Form is used for Medi-Cal beneficiaries in California to request redetermination for long-term care in their own Medi-Cal-funded beds.

This Form is used for determining eligibility and calculating co-payment for the Community Care for the Elderly (CCE) and Alzheimer's Disease Initiative (ADI) programs in Florida.

This form is used for assessing assets in order to determine eligibility for Medical Assistance for Long-Term Care Services in Minnesota.

This form is used for redetermining eligibility for long-term care and waiver medical assistance in Maryland.

This form is used for requesting admission to an Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID) or a State-Operated Nursing Facility (SONF) in Washington state.