Get Chcpe Request For Referral

The Chcpe Request For Referral is a vital document for individuals 65 years and older seeking assistance through the Connecticut Home Care Program for Elders. This guide will walk you through each section of the form to ensure a smooth and efficient online submission process.

Follow the steps to complete the Chcpe Request For Referral online.

1. Press the ‘Get Form’ button to download the form and open it in your preferred editor.
2. Begin with Section A, which requires the applicant's personal information. Fill in the applicant's last name, first name, date of birth, marital status, social security number, and gender. Also, provide the applicant's current address and phone number.
3. In Section B, indicate the applicant's monthly income and total assets. Be sure to answer the question about the spousal assessment by selecting 'Yes' or 'No' based on the situation.
4. Proceed to Section C, which focuses on functional assessment. Here, you will need to provide information about personal needs by indicating how much assistance is required for various activities, including bathing, dressing, and medication.
5. In the same section, describe the applicant's living arrangements and indicate if they receive help from family or community members. Also, note any behavioral problems applicable.
6. Fill in the medical diagnosis or condition as requested in Section C.
7. If someone other than the applicant is the point of contact, fill out Section D with their name, contact number, relationship to the applicant, and their role.
8. Complete the form with the applicant's signature or mark, and date it. If someone else is completing the form on behalf of the applicant, they should indicate their relation and fill in their contact information.
9. If applicable, have a witness sign if the applicant used a mark, and complete the facility staff section if the applicant is in a hospital or nursing home.
10. Finally, review all sections to ensure completeness, save changes, and prepare to download, print, or share the form as needed.

Complete your Chcpe Request For Referral online today for assistance in receiving the necessary care.