Follow the steps to successfully fill out the MnCHOICES Referral Form.

1. Click ‘Get Form’ button to access the MnCHOICES Referral Form and open it in the online editor.
2. Fill in the date of the referral and provide the referral source's name and phone number. Include the referral source's relationship to the individual referred.
3. Provide the client information, including their name, date of birth, social security number, marital status, PMI, address (including ZIP code, city, and state), phone number, county of financial responsibility, email address, and their preference for contact method.
4. Indicate if an interpreter is needed and specify the language spoken. Confirm if the individual is certified disabled by selecting ‘Yes’ or ‘No’. If yes, provide details related to the medical review team and waiver program if applicable.
5. Specify the individual's sex and list the services they are currently receiving, as well as any services they are interested in.
6. Describe the current living situation of the individual, including whether they live alone or with others, and detail the type of living arrangements.
7. Indicate if the individual has someone who helps make decisions about their health care and financial matters, and provide details about this person, including their name, relationship, address, and contact information.
8. Fill out the emergency contact section with the name, relationship, address, and contact details of the emergency person.
9. Complete the insurance and financial status section by providing information about medical assistance, private insurance, and the individual's financial status regarding liquid assets.
10. List the names and contact information of primary physician, mental health provider, home care agency, and any other relevant providers.
11. Document any diagnoses and the types of assistance needed in various areas, such as mobility, grooming, toileting, and other health-related activities.
12. Clarify the referral reason, including any caregiver needs, safety concerns, or other supports requested. Provide comments as necessary.
13. Review all information for completeness and accuracy before final submission.
14. Save changes and either download, print, or share the completed form as an attachment via email or fax to the Long Term Services and Supports Intake.

Start completing the MnCHOICES Referral Form online today to ensure timely access to necessary services.