New Jersey Department of Human Services

Division of Aging Services

Assisted Living/Adult Family Care (AL/AFC) Referral

FOR THE Managed long term services and supports (mltss) MEDICAID WAIVER

APPLICANT BACKGROUND INFORMATION
Name of Applicant (First, Middle Initial, Last)

Social Security Number

Street Address

Date of Birth

City, State, Zip Code

Telephone Number

Medicaid Application Filed at CWA?

Yes No	County of Application

Caregiver/Legal Representative

Telephone Number

Referring AL/AFC Provider

Telephone Number

Reason for Referral

Spend Down New Admit	NOTE: The processing of the AL/AFC Referral Form does not constitute enrollment on the MLTSS Medicaid Waiver nor does it guarantee residency for the applicant at the referring AL/AFC facility.
APPLICANT CLINICAL INFORMATION
Diagnosis

Check off the level of assistance the applicant requires for EACH Activity of Daily Living (ADL):
Activities of Daily Living (ADL)	Independent	Supervision/ Cueing	Limited

Assist or Greater
Cognitive Status	Intact	Impaired
Short Term Memory
Bathing
Procedural Memory
Dressing
Decision Making
Bed Mobility
MLTSS Waiver Target Population Criteria
Eating
Aged 65+, or

Physically Disabled Age 21-64	Yes No
Locomotion
Toilet Use
Age 21-64 with MR/DD/Chronic MI	Yes* No
Transfer
* If Yes, the applicant is ineligible for MLTSS and the AL facility is to counsel the applicant on other options.
Other Care Needs

Social Information/Family Supports

APPLICANT FINANCIAL INFORMATION
Monthly Income
Resources (bank accounts, stocks, bonds, etc.)
Social Security
Pension
Other
Total Monthly Income
Face Value of Life Insurance Policy(ies), if known:
Name of Individual Completing Form (Print)

Title

Signature

Date

AL-6

MAR 15	Note:	If applicant is found eligible for the MLTSS Medicaid Waiver, there may be a cost share to the applicant, which is dependent on his or her income and allowable deductions.

AL-6, Assisted Living/Adult Family Care (AL/AFC) Referral

assisted living, AL-6, adult family care, referral, long term care, Division of Aging Services, AL, AFC, DAS

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2015-03-17

human services