Are you sure you want to exit? Your progress will be lost.
Who are you caring for?
Which best describes their mobility?
How well are they maintaining their hygiene?
How are they managing their medications?
Does their living environment pose any safety concerns?
Fall risks, spoiled food, or other threats to wellbeing
Are they experiencing any memory loss?
Which best describes your loved one's social life?
Acknowledgment of Disclosures and Authorization
By proceeding, I agree that I understand the following disclosures:
I. How We Work in Washington. Based on your preferences, we provide you with information about one or more of our contracted senior living providers ("Participating Communities") and provide your Senior Living Care Information to Participating Communities. The Participating Communities may contact you directly regarding their services. APFM does not endorse or recommend any provider. It is your sole responsibility to select the appropriate care for yourself or your loved one. We work with both you and the Participating Communities in your search. We do not permit our Advisors to have an ownership interest in Participating Communities.
II. How We Are Paid. We do not charge you any fee – we are paid by the Participating Communities. Some Participating Communities pay us a percentage of the first month's standard rate for the rent and care services you select. We invoice these fees after the senior moves in.
III. When We Tour. APFM tours certain Participating Communities in Washington (typically more in metropolitan areas than in rural areas.) During the 12 month period prior to December 31, 2017, we toured 86.2% of Participating Communities with capacity for 20 or more residents.
IV. No Obligation or Commitment. You have no obligation to use or to continue to use our services. Because you pay no fee to us, you will never need to ask for a refund.
V. Complaints. Please contact our Family Feedback Line at (866) 584-7340 or ConsumerFeedback@aplaceformom.com to report any complaint. Consumers have many avenues to address a dispute with any referral service company, including the right to file a complaint with the Attorney General's office at: Consumer Protection Division, 800 5th Avenue, Ste. 2000, Seattle, 98104 or 800-551-4636.
VI. No Waiver of Your Rights. APFM does not (and may not) require or even ask consumers seeking senior housing or care services in Washington State to sign waivers of liability for losses of personal property or injury or to sign waivers of any rights established under law.I agree that: A.I authorize A Place For Mom ("APFM") to collect certain personal and contact detail information, as well as relevant health care information about me or from me about the senior family member or relative I am assisting ("Senior Living Care Information"). B.APFM may provide information to me electronically. My electronic signature on agreements and documents has the same effect as if I signed them in ink. C.APFM may send all communications to me electronically via e-mail or by access to an APFM web site. D.If I want a paper copy, I can print a copy of the Disclosures or download the Disclosures for my records. E.This E-Sign Acknowledgement and Authorization applies to these Disclosures and all future Disclosures related to APFM's services, unless I revoke my authorization. You may revoke this authorization in writing at any time (except where we have already disclosed information before receiving your revocation.) This authorization will expire after one year. F.You consent to APFM's reaching out to you using a phone system than can auto-dial numbers (we miss rotary phones, too!), but this consent is not required to use our service.
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I acknowledge and authorize
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I consent to the collection of my consumer health data.*
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Mostly Independent
Your loved one may not require home care or assisted living services at this time. However, continue to monitor their condition for changes and consider occasional in-home care services for help as needed.
Remember, this assessment is not a substitute for professional advice.
Share a few details and we will match you to trusted home care in your area:
medi-cal annual re determination notice asks about family members but sister applying is a formerly married disabled adult. Forms seem to be geared towards family other than this situation.
Oh this is a bag of worms! Since the last time you filed this form, has this persons living situation changed? You say she was once married and is now divorced and is disabled, but has she now moved in with another family member? Anytime anything changes for the Medi Cal/Medicaid recipient then you are suppose to call and notify them immediately. This is because she may no longer be eligible if she is in a better living situation.
Either find out who her social worker is and call them and ask for help, or go ahead and fill it out and on the bottom there is a section to add more information make a notation that she is now divorced and disabled and living with your Mom. Believe me they will follow up with you!!!! They will probably send you a notice stating that her Medicaid is pending additional information.
YOU NEED TO MAKE A COPY OF THE FORM AND KEEP IT IN A FILE ALONG WITH ALL PAPERWORK FROM THEM. WHEN YOU FILL IT OUT NEXT YEAR ALSO MAKE A COPY AND KEEP IT, YOU NEED TO HOLD ON TO COPIES OF ALL OF THESE SO YOU CAN LOOK BACK AND SEE WHAT YOU ANSWERED THE YEAR BEFORE.
Attach proof of disability, usually a letter of determination from SSI. Also attach copy of the divorce, this is crucial. If she pays your mother rent/ utilities, show it. Ask her MD to give you a letter stating her current condition and percent disability.
There must be space on the forms for comments where you could explain the situation. I would contact your local Sr. center for help. Is their a contact name or no. on the forms that you can call & ask for help to complete the forms ? I have annual forms to fill out for my disabled family member & they do ask a lot of info that I cannot answer to. I have called the Social worker where the forms came from & they were helpful. Some of the questions she told me to write in N/A ( non applicable ) . Good luck, the forms are tough !
By proceeding, I agree that I understand the following disclosures:
I. How We Work in Washington.
Based on your preferences, we provide you with information about one or more of our contracted senior living providers ("Participating Communities") and provide your Senior Living Care Information to Participating Communities. The Participating Communities may contact you directly regarding their services.
APFM does not endorse or recommend any provider. It is your sole responsibility to select the appropriate care for yourself or your loved one. We work with both you and the Participating Communities in your search. We do not permit our Advisors to have an ownership interest in Participating Communities.
II. How We Are Paid.
We do not charge you any fee – we are paid by the Participating Communities. Some Participating Communities pay us a percentage of the first month's standard rate for the rent and care services you select. We invoice these fees after the senior moves in.
III. When We Tour.
APFM tours certain Participating Communities in Washington (typically more in metropolitan areas than in rural areas.) During the 12 month period prior to December 31, 2017, we toured 86.2% of Participating Communities with capacity for 20 or more residents.
IV. No Obligation or Commitment.
You have no obligation to use or to continue to use our services. Because you pay no fee to us, you will never need to ask for a refund.
V. Complaints.
Please contact our Family Feedback Line at (866) 584-7340 or ConsumerFeedback@aplaceformom.com to report any complaint. Consumers have many avenues to address a dispute with any referral service company, including the right to file a complaint with the Attorney General's office at: Consumer Protection Division, 800 5th Avenue, Ste. 2000, Seattle, 98104 or 800-551-4636.
VI. No Waiver of Your Rights.
APFM does not (and may not) require or even ask consumers seeking senior housing or care services in Washington State to sign waivers of liability for losses of personal property or injury or to sign waivers of any rights established under law.
I agree that:
A.
I authorize A Place For Mom ("APFM") to collect certain personal and contact detail information, as well as relevant health care information about me or from me about the senior family member or relative I am assisting ("Senior Living Care Information").
B.
APFM may provide information to me electronically. My electronic signature on agreements and documents has the same effect as if I signed them in ink.
C.
APFM may send all communications to me electronically via e-mail or by access to an APFM web site.
D.
If I want a paper copy, I can print a copy of the Disclosures or download the Disclosures for my records.
E.
This E-Sign Acknowledgement and Authorization applies to these Disclosures and all future Disclosures related to APFM's services, unless I revoke my authorization. You may revoke this authorization in writing at any time (except where we have already disclosed information before receiving your revocation.) This authorization will expire after one year.
F.
You consent to APFM's reaching out to you using a phone system than can auto-dial numbers (we miss rotary phones, too!), but this consent is not required to use our service.
Either find out who her social worker is and call them and ask for help, or go ahead and fill it out and on the bottom there is a section to add more information make a notation that she is now divorced and disabled and living with your Mom. Believe me they will follow up with you!!!! They will probably send you a notice stating that her Medicaid is pending additional information.
YOU NEED TO MAKE A COPY OF THE FORM AND KEEP IT IN A FILE ALONG WITH ALL PAPERWORK FROM THEM. WHEN YOU FILL IT OUT NEXT YEAR ALSO MAKE A COPY AND KEEP IT, YOU NEED TO HOLD ON TO COPIES OF ALL OF THESE SO YOU CAN LOOK BACK AND SEE WHAT YOU ANSWERED THE YEAR BEFORE.
I would contact your local Sr. center for help.
Is their a contact name or no. on the forms that you can call & ask for help to complete the forms ?
I have annual forms to fill out for my disabled family member & they do ask a lot of info that I cannot answer to. I have called the Social worker where the forms came from & they were helpful.
Some of the questions she told me to write in N/A ( non applicable ) .
Good luck, the forms are tough !