Get Mn Mnchoices Assessment Referral Form - Anoka County 2023-2025

This guide provides a step-by-step approach to completing the MN MnCHOICES Assessment Referral Form for Anoka County online. It is designed to assist users in accurately filling out the form to facilitate access to necessary services.

Follow the steps to successfully complete the assessment referral form.

1. Click ‘Get Form’ button to obtain the MN MnCHOICES Assessment Referral Form and open it for editing.
2. Fill in the date at the top of the form to indicate when the referral is being made. Ensure the date is accurate.
3. Complete the referral source section by providing your name, phone number, and your relationship to the individual being referred.
4. In the client information section, enter the individual's name, date of birth, social security number, and marital status. Select the appropriate options for sex and address.
5. Provide the county of financial responsibility and email address. Indicate how you prefer to be contacted, and note if an interpreter is needed, along with the primary language spoken.
6. Check the box indicating if the person is certified disabled. If yes, specify the programs in which they are interested.
7. Detail the services currently received by the individual, including any personal care assistance, case management, or other in-home services.
8. Describe the current living situation by selecting from the provided options and indicating who the individual currently resides with.
9. In the legal authority section, indicate if someone is available to assist with decision-making and provide their information if applicable.
10. Fill in the emergency contact details, including the name, relationship, address, phone number, and email.
11. Enter insurance and financial status details, specifying if the individual is on Medical Assistance and detailing their financial assets.
12. List primary and secondary healthcare providers. Include all relevant contact information for these providers.
13. Document any diagnoses and the assistance the individual needs in various areas, as indicated in the form.
14. Provide reasons for the referral in the designated section, including any caregiver needs, safety concerns, or behavioral issues.
15. After completing all sections, save your changes. You can then download, print, or share the form as an attachment to the specified email or via fax.

Start filling out the MN MnCHOICES Assessment Referral Form online to ensure timely access to essential services.