Get Mn Accessible Space Customized Living And Community Residential Services Request Form 2022-2025

Filling out the MN Accessible Space Customized Living and Community Residential Services Request Form online can be a straightforward process. This guide will walk you through each section of the form, ensuring you understand what information is required and how to complete it efficiently.

Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to obtain the form and open it in an online editor.
2. Begin by entering the date of application, followed by the individual’s name and date of birth. Ensure that all required personal information is accurate and clearly stated.
3. Fill in the individual’s gender, phone number, and address. It is important to provide complete contact details for further communication.
4. Input the medical assistance number and any other insurance details, along with the social security number. Be cautious while entering sensitive information.
5. Indicate the individual’s gross monthly income and any monthly spend down that applies. This information is crucial for determining eligibility for services.
6. Provide the individual’s email, diagnosis, onset date, height, approximate weight, and a description of any injury or condition, ensuring that all information is current and accurate.
7. Complete the emergency contact section by providing a name, relationship, phone number, and email address. Include information regarding the county waiver type applicable to your situation.
8. Declare any services currently being received, such as a relocation service coordinator or mental health case manager, including their names and contact information.
9. Fill out sections on the living situation, including whether the individual resides in a health or nursing facility and the relevant facility details.
10. Complete the housing history and medical history sections, listing relevant facilities and providers as well as reasons for moving, ensuring you provide accurate and thorough information.
11. Mark any necessary community living services requested, completing all sections related to supports required.
12. After reviewing all sections for accuracy, save your changes, download a copy for your records, and print if needed, or share the filled-out form via email to the indicated contact.

Start filling out the document online today to access the support you need.