Attachment 2 "Assisted Living Enhanced Care Referral Form" - Rhode Island

What Is Attachment 2?

This is a legal form that was released by the Rhode Island Executive Office of Health and Human Services - a government authority operating within Rhode Island. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2020;
  • The latest edition provided by the Rhode Island Executive Office of Health and 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 Attachment 2 by clicking the link below or browse more documents and templates provided by the Rhode Island Executive Office of Health and Human Services.

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Download Attachment 2 "Assisted Living Enhanced Care Referral Form" - Rhode Island

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3 West Road | Virks Building | Cranston, RI 02920
Attachment 2 - Assisted Living Enhanced Care Referral Form
Instructions: Complete this referral form and fax to OHA Case Management Agency
Section I: Referral Information
Today’s Date: ________________________
Name of Referrer: ___________________________ Phone: _______________ Fax: ____________
Assisted Living Residence: _______________________________ Phone: _______________________
ALR Address: ________________________________ City: _____________ State: _____ Zip: __________
Section II: Client Information
Client Name: _____________________________________ Phone: ___________________
DOB: ______________________ SSN#________________________
Address: ____________________________________ City:_____________ State:_____ Zip: __________
Primary Contact: ______________________ Relationship: _____________ Phone: _________________
Address: ___________________________________ City: ____________ State:_____ Zip:___________
YES
NO Comments
Currently on Medicaid
Date:
AL Program?
Currently receiving
Date:
Category D?
Applying for LTSS
Date:
Medicaid?
Current Income
January 2020
3 West Road | Virks Building | Cranston, RI 02920
Attachment 2 - Assisted Living Enhanced Care Referral Form
Instructions: Complete this referral form and fax to OHA Case Management Agency
Section I: Referral Information
Today’s Date: ________________________
Name of Referrer: ___________________________ Phone: _______________ Fax: ____________
Assisted Living Residence: _______________________________ Phone: _______________________
ALR Address: ________________________________ City: _____________ State: _____ Zip: __________
Section II: Client Information
Client Name: _____________________________________ Phone: ___________________
DOB: ______________________ SSN#________________________
Address: ____________________________________ City:_____________ State:_____ Zip: __________
Primary Contact: ______________________ Relationship: _____________ Phone: _________________
Address: ___________________________________ City: ____________ State:_____ Zip:___________
YES
NO Comments
Currently on Medicaid
Date:
AL Program?
Currently receiving
Date:
Category D?
Applying for LTSS
Date:
Medicaid?
Current Income
January 2020
January 2020
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