(10/1/09 ML #3199)
Purpose: For individuals to formally request Home and Community Based Services and Medicaid State Plan Personal Care Service.
Prior to conducting a comprehensive assessment, an applicant (or legal representative) must complete the application form.
Date – date of application;
Agency – County Social Service Board of applicant’s physical county;
Name – print the name of the applicant (one SFN 1047 per applicant);
I apply for services to assist me with – the applicant indicates what services or programs for which the applicant is requesting assistance;
FOR YOUR INFORMATION – applicant must read this section prior to signing;
The applicant must check to acknowledge the receipt of the "Your Rights and Responsibilities" brochure. (The Brochure # is DN46 (0606)
Signature section – the applicant and/or the legal representative must sign and date the application form.