Form AL-6 "Assisted Living/Adult Family Care (Al/Afc) Referral for the Managed Long Term Services and Supports (Mltss) Medicaid Waiver" - New Jersey

What Is Form AL-6?

This is a legal form that was released by the New Jersey Department of Human Services - a government authority operating within New Jersey. Check the official instructions before completing and submitting the form.

Form Details:

  • Released on March 1, 2015;
  • The latest edition provided by the New Jersey Department of Human Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form AL-6 by clicking the link below or browse more documents and templates provided by the New Jersey Department of Human Services.

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Download Form AL-6 "Assisted Living/Adult Family Care (Al/Afc) Referral for the Managed Long Term Services and Supports (Mltss) Medicaid Waiver" - New Jersey

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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?
County of Application
Yes
No
Caregiver/Legal Representative
Telephone Number
Referring AL/AFC Provider
Telephone Number
Reason for Referral
NOTE:
The processing of the AL/AFC Referral Form does not constitute
enrollment on the MLTSS Medicaid Waiver nor does it guarantee residency for
Spend Down
New Admit
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
Limited
Cognitive Status
Intact
Impaired
Supervision/
Daily Living
Independent
Assist or
Cueing
Short Term Memory
(ADL)
Greater
Bathing
Procedural Memory
Dressing
Decision Making
Bed Mobility
MLTSS Waiver Target Population Criteria
Eating
Aged 65+, or
Yes
No
Locomotion
Physically Disabled Age 21-64
Toilet Use
Age 21-64 with MR/DD/Chronic MI
Yes*
No
* If Yes, the applicant is ineligible for MLTSS and the AL
Transfer
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
Note:
If applicant is found eligible for the MLTSS Medicaid Waiver, there may be a cost share to the
AL-6
applicant, which is dependent on his or her income and allowable deductions.
MAR 15
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?
County of Application
Yes
No
Caregiver/Legal Representative
Telephone Number
Referring AL/AFC Provider
Telephone Number
Reason for Referral
NOTE:
The processing of the AL/AFC Referral Form does not constitute
enrollment on the MLTSS Medicaid Waiver nor does it guarantee residency for
Spend Down
New Admit
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
Limited
Cognitive Status
Intact
Impaired
Supervision/
Daily Living
Independent
Assist or
Cueing
Short Term Memory
(ADL)
Greater
Bathing
Procedural Memory
Dressing
Decision Making
Bed Mobility
MLTSS Waiver Target Population Criteria
Eating
Aged 65+, or
Yes
No
Locomotion
Physically Disabled Age 21-64
Toilet Use
Age 21-64 with MR/DD/Chronic MI
Yes*
No
* If Yes, the applicant is ineligible for MLTSS and the AL
Transfer
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
Note:
If applicant is found eligible for the MLTSS Medicaid Waiver, there may be a cost share to the
AL-6
applicant, which is dependent on his or her income and allowable deductions.
MAR 15