"Options Counseling/Community Transition Referral Information Form" - Colorado

Options Counseling/Community Transition Referral Information Form is a legal document that was released by the Colorado Department of Health Care Policy and Financing - a government authority operating within Colorado.

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Options Counseling/Community Transition Referral Information Form
Options Counseling Agency  _______________________________________________________ 
Transition Coordination Agency ____________________________________________________ 
Transition Coordinator ___________________________________________________________ 
Print Client Name _______________________________________________________________          
Print Client Nickname ________________________________________        DOB ____________         
       
Disability Type:   Elderly ☐
Mental Illness ☐
Physical ☐
Intellectual Disability ☐   
Referral Type:     Self ☐ 
MDS Section Q ☐         Other ☐ ____________________________  
Nursing Facility _________________________________________________________________ 
Nursing Facility Contact Name _____________________________________________________ 
Phone Number _____________________            E‐Mail _________________________________ 
Phone Number for Client _________________________________________________________ 
 
Guardian Name (if applicable) _____________________________________________________ 
Contact Information _____________________________________________________________ 
 
Medicaid Eligible   ☐ Yes   ☐ No   ☐ Pending  
   Medicaid # _________________________ 
If Medicaid Eligible:   Long Term Care Medicaid   ☐ Yes   ☐ No  
 
Nursing facility admission date ____________________________________ 
Copy of doctor’s admitting orders received___________________________________________ 
Physician name _________________________________________________________________ 
Contact information _____________________________________________________________ 
 
Availability of the following information: 
☐Yes   ☐No            ID   ☐Yes   ☐No  
Driver’s License   ☐Yes   ☐No   
Proof of Income   
Social Security Card    ☐Yes   ☐No   
Birth Certificate   ☐Yes   ☐No     
 
 
 
Housing subsidy needed:    ☐ Yes   ☐ No      
Date/Time Initial Visit Scheduled ___________________________________________________ 
Resident Statement: 
☐ I will explore opportunities to make the transition to living in the community. 
☐ I have decided not to move into the community at this time. 
Signature: ___________________________________________   Date: ____________________ 
Printed Name: __________________________________________________________________ 
☐ Resident 
☐ Legal Guardian 
☐ Legal Representative  
 
 
 
 
Colorado Department of Health Care Policy and Financing
 
 
Options Counseling/Community Transition Referral Information Form
Options Counseling Agency  _______________________________________________________ 
Transition Coordination Agency ____________________________________________________ 
Transition Coordinator ___________________________________________________________ 
Print Client Name _______________________________________________________________          
Print Client Nickname ________________________________________        DOB ____________         
       
Disability Type:   Elderly ☐
Mental Illness ☐
Physical ☐
Intellectual Disability ☐   
Referral Type:     Self ☐ 
MDS Section Q ☐         Other ☐ ____________________________  
Nursing Facility _________________________________________________________________ 
Nursing Facility Contact Name _____________________________________________________ 
Phone Number _____________________            E‐Mail _________________________________ 
Phone Number for Client _________________________________________________________ 
 
Guardian Name (if applicable) _____________________________________________________ 
Contact Information _____________________________________________________________ 
 
Medicaid Eligible   ☐ Yes   ☐ No   ☐ Pending  
   Medicaid # _________________________ 
If Medicaid Eligible:   Long Term Care Medicaid   ☐ Yes   ☐ No  
 
Nursing facility admission date ____________________________________ 
Copy of doctor’s admitting orders received___________________________________________ 
Physician name _________________________________________________________________ 
Contact information _____________________________________________________________ 
 
Availability of the following information: 
☐Yes   ☐No            ID   ☐Yes   ☐No  
Driver’s License   ☐Yes   ☐No   
Proof of Income   
Social Security Card    ☐Yes   ☐No   
Birth Certificate   ☐Yes   ☐No     
 
 
 
Housing subsidy needed:    ☐ Yes   ☐ No      
Date/Time Initial Visit Scheduled ___________________________________________________ 
Resident Statement: 
☐ I will explore opportunities to make the transition to living in the community. 
☐ I have decided not to move into the community at this time. 
Signature: ___________________________________________   Date: ____________________ 
Printed Name: __________________________________________________________________ 
☐ Resident 
☐ Legal Guardian 
☐ Legal Representative  
 
 
 
 
Colorado Department of Health Care Policy and Financing