Get Ltc Screening Manual Referral Form Type Of Assessment

The LTC Screening Manual Referral Form Type of Assessment is a crucial document used for evaluating individuals seeking long-term care services. This guide will walk you through the steps needed to complete the form accurately and efficiently online.

Follow the steps to complete the form online.

1. Click 'Get Form' button to obtain the form and open it for completion.
2. Begin with the Client Demographics section. Enter the referral date, the client’s full name, and date of birth (DOB). It is essential to ensure that this information is accurate and up to date.
3. Provide the client's address information including street address, city, state, and zip code. If applicable, include P.O. Box details.
4. Indicate the client's sex and provide their social security number, along with Medicare and Medicaid numbers if available.
5. Next, specify whether the client is their own primary contact and provide their marital status. Fill in the appropriate home and work phone numbers, and email address for communication.
6. Complete the Emergency Contact section, noting the relationship to the client, and provide their address and phone numbers.
7. In the Reason for Referral section, detail the medical diagnosis and note any recent hospital or nursing facility admissions. Include the names of the facilities and reasons for admission, along with relevant dates.
8. Under Formal Agency Services, provide the organization name and type of services received by the client.
9. Complete the Primary Physician section with the physician’s name, mailing address, and contact details, including phone and fax numbers.
10. In the Finances section, input the client's and, if applicable, their spouse’s monthly income and details of assets.
11. Finally, indicate the level of assistance required for Activities for Daily Living by marking the appropriate boxes for each activity listed.
12. Once all sections are filled out correctly, save your changes. You can then download, print, or share the form as needed.

Complete the LTC Screening Manual Referral Form Type Of Assessment online today for efficient processing and assessment.