Get Lt101 Referral Wyoming

The Lt101 Referral form is crucial for facilitating the transition of individuals into nursing facilities in Wyoming. This guide provides a step-by-step approach to filling out the form online, ensuring that users can navigate the process with ease.

Follow the steps to complete the Lt101 Referral form accurately.

1. Press the ‘Get Form’ button to access the Lt101 Referral form and open it in your preferred editor.
2. Begin by entering the date of request in the designated field. This should be the date you are submitting the form.
3. Fill in the facility name and address where the individual will be admitted.
4. Provide the name and phone number of the person requesting the referral.
5. Enter the client's name and social security number (SSN) in the specified fields.
6. Indicate whether the client is currently in the facility by selecting 'Yes' or 'No.' If 'No,' provide the client's location.
7. If applicable, input the anticipated date of entry into the nursing facility.
8. Fill in the client's address and phone number if they are not currently in the facility.
9. Select 'Yes' or 'No' to indicate if the Lt101 consent has been signed.
10. If the client is in the facility, enter their room number. Also, indicate whether there are any pertinent chart notes.
11. Specify whether the client currently has Medicaid and if they are applying for Medicaid.
12. List the client's primary diagnosis and, if available, their Medicaid number and original admit date.
13. Indicate if an LT101 was completed previously and for what reason (e.g., Admit, Medicaid Application, PASRR Level II).
14. Provide information regarding where the client is being admitted from and add any additional notes that may be relevant.
15. Once all information is complete, save changes to the form. You can then print, download, or share the completed document.

Start completing the Lt101 Referral form online today to ensure a smooth transition for your client.