CMA - Long Term Care Services and Supports

Date

MonthDayYear
Date
Hour MinutesAM/PM Option
Age
Long Term Care Services and Supports

ULTC 100.2 Initial Screening and Intake
Applicant Information
State ID
County ID
Name*

First NameMiddle NameLast Name
Primary Language
Date of Birth*

MonthDayYear
Social Security Number
Marital Status

SingleMarriedDivorcedWidowed
Phone Number*
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Email*
example@example.com
Physical Address (current location of applicant)

Street Address

Street Address Line 2

CityState

Zip Code
Identification Verification Document Upload

Cancelof

Authorized Representative / Legal Guardian Information
Representative/Guardian Name

First NameLast Name
Relationship
Email
example@example.com
1st Phone Number
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2nd Phone Number
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Preferred method of contact

EmailPhone
Mailing Address

Street Address

Street Address Line 2

CityState

Zip Code

Financial Information

Client Income Source(s)

	Enter an Amount if Applicable per Month (in $)
SSA/SSDI
SSI
Employment
OAP
AND/AB
Other Income

Client Monthly Gross Income
(Automatically Calculated)
Client Owned Assets

Spouse Income Source(s)

	Enter an Amount if Applicable per Month (in $)
SSA/SSDI
SSI
Employment
OAP
AND/AB
Other Income

Spouse Monthly Gross Income
(Automatically Calculated)
Spouse Owned Assets

Insurance Information
Client's Insurance Information

VA BenefitsMedicare Part AMedicare Part BMedicaidLTC MedicaidMedicaid Pending?
Medicaid Pending Status?

Application in ProcessApplication NeededApplication Mailed
When was the Medicaid application mailed?

MonthDayYear
Date
Comments

Medical Provider Information
Professional Medical Information Page Sent To Provider?
Click the link below for a blank copy.

Professional Medical Information Page
Provider Name
Type of Provider
Provider Phone Number
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Provider Fax Number
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Provider Email
example@example.com
Provider Contact
Provider Address

Street Address

Street Address Line 2

CityState

Zip Code
Comments

Authorization for Disclosure of Protected Heatlh Information (PHI)
In order to facilitate the administration of my public assistance benefits by the Long Term Care Case Management Agency System, Jefferson County Case Management Agency (Jeffco CMA), I hereby authorize my physician and any other health care provider, including but not limited to hospitals, pharmacies, medical equipment suppliers, home health agencies, homemaker and personal care providers insurance carriers and other social services organizations, including mental health service providers, to release my Protected Health Information (PHI) to Jeffco CMA.

I understand that the case managers of the Jeffco CMA are endeavoring to coordinate my health and wellness in the least restrictive placement setting. Towards that goal, I authorize my case manager to discuss my care and treatment with those same individuals and agencies described in the preceding paragraph, understanding that in so doing, protected health information may necessarily be exchanged or disclosed by the case manager.
In addition, I am authorizing the release of my protected health information by the Jeffco CMA to the following designated individual(s):
My protected health information (PHI) is being released to Jeffco CMA, its agents and subcontractors, for use in determining my eligibility for services, for case management or supervision of my services, for analyzing and determining what services I should receive, or to obtain other services for me through the Department of Human Services, the State of Colorado, or the United States. Medical information provided pursuant to this disclosure may be subject to re-disclosure to an Administrative Law Judge or other agent of the State of Colorado in the event I appeal a determination regarding my eligibility for benefits.

This authorization will expire one year from the date it is signed. If you intend to revoke the authorization sooner, you must provide written revocation to your case manager at:
Jefferson County Human Services, 900 Jefferson County Parkway Room 170, Golden, CO 80401.
Signature

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Date

MonthDayYear
Date
Name

First NameLast Name
PROVIDE A COPY TO THE PERSON SIGNING THIS AUTHORIZATION.
RETAIN THIS AUTHORIZATION 6 YEARS AFTER ITS EXPIRATION.

Authorization form: 164.508 (c)

Client or Representative Signature
I certify that the accompanying information accurately reflects information given by me or on my behalf on the date specified. I understand that this information is used as a basis for scheduling an assessment and agree to be assessed for all Medicaid Long Term Care benefits administered by the above agency.
Client or Representative Signature

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Long Term Care Services and Supports

Applicant Information

Authorized Representative / Legal Guardian Information

Further Applicant Information

Presenting Problems and Diagnoses

Areas of Concern

Waiver Options

Non-Waiver Program Options

Information and Referral Provided

Referral Information

Financial Information

Insurance Information

Medical Provider Information

Authorization for Disclosure of Protected Heatlh Information (PHI)

Client or Representative Signature