STATE OF WISCONSIN DEPARTMENT OF HEALTH SERVICES Division of Long Term Care F-21051 (03/2012) CIP COMMUNITY LONG TERM CARE SERVICES REFERRAL TO INCOME MAINTENANCE WORKER (IMW) This is a voluntary.
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How to fill out the Cip F 21051 online
Filling out the Cip F 21051 form is essential for users seeking community long-term care services in Wisconsin. This guide provides clear, step-by-step instructions to assist you in completing the form online with ease.
Follow the steps to successfully complete the Cip F 21051 form online.
- Click ‘Get Form’ button to obtain the Cip F 21051 form and open it in your preferred editing environment.
- Begin by entering the applicant’s Social Security Number and Medicaid Number if different. This information is crucial for identification purposes.
- Fill in the applicant's name by entering the last name, first name, and middle initial in the designated fields.
- Provide the applicant's street address, including city, state, and zip code to ensure proper correspondence.
- Enter the applicant's date of birth in the specified format provided in the form.
- Include a telephone number where the applicant can be reached.
- Indicate the marital status of the applicant by checking the appropriate box (Single, Divorced, Married, Widowed).
- Describe the living arrangement by selecting one of the options provided, including specifying if 'Other' is applicable.
- Fill in the contact person's name, telephone number, and their relationship to the applicant. This could be a guardian, financial representative, or any authorized person.
- Specify the date of the initial request for community waiver and include details about whether the applicant is a 'transfer' to or from a Family Care County.
- Enter the anticipated waiver start date and the date of referral from the care manager or support and service coordinator.
- List the name and telephone number of the care manager or support and service coordinator assisting with the application.
- Select the appropriate long-term care program target group eligibility by checking one of the options listed.
- Indicate the level of care (LOC) required by selecting one of the choices provided for PACE/Partnership Agencies.
- Provide information about functional eligibility by selecting 'Yes' or 'No' as applicable.
- Enter any special housing amounts if applicable, along with the costs of monthly out-of-pocket remedial and medical expenses.
- Select a plan for processing the application, indicating if the care manager or IM worker will arrange appointments.
- Review all information filled out to ensure accuracy before submitting the form.
- Once the form is completely filled out, you can save changes, download, print, or share the completed form as necessary.
Complete your Cip F 21051 form online today to ensure efficient processing of your community long-term care services request.
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