ࡱ> c Ibjbj 7.jfjff 8Q$u$|#&("""""""$%X(d!#!#46#R""r!T+"X7HG!"L#0|#!2(e(+"(+"!#!# |#( : Date of Request:________________________________ Date current APRC ends: ______________________________ Residents Name:_________________________________________ fb88Care #:______________________________ Social Security #: _________________________________________ Date of Birth: _____________________________ Facility: _______________________________________________ Phone ____________________________________ Address: _______________________________________________ Fax # ____________________________________ _______________________________________________ Person filing: ______________________________ Does the resident have a legal guardian or some other family member who should also be notified of the APRC determination? Name: ______________________________________________________Relationship: _________________________ Address: ____________________________________________________ Phone:_______________________________ Date of Admission:__________________________________________________________________________________ Update on in-home services: How could the resident be safely discharged home or to an apartment or other non-institutional setting? Please explain services that would be needed/ programs that might be accessed/ contacts you have made with the Home Care/Service Coordination Agencies, Area Agencies, home health agencies, or other appropriate agencies. __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Most recent contacts with appropriate residential care facilities within a 60 mile radius of the facility or the residents home, if applicable: Facility name: ________________________________________________________________________________ Address: _____________________________________________________________________________________ _____________________________________________________________________________________ Phone #__________________________Contact person at facility:________________________________________ Date (s) facility was contacted: ____________________________________________________________________ What type of resident do they serve? _______________________________________________________________ Does the facility have any vacancies?[ ] yes [ ] no Is your resident on their waiting list? [ ] yes [ ] no Est. time to reach the top of the list: __________________ Facility name: ________________________________________________________________________________ Address: _____________________________________________________________________________________ _____________________________________________________________________________________ Phone #__________________________Contact person at facility:________________________________________ Date (s) facility was contacted: ____________________________________________________________________ What type of resident do they serve? _______________________________________________________________ Does the facility have any vacancies?[ ] yes [ ] no Is your resident on their waiting list? [ ] yes [ ] no Est. time to reach the top of the list: __________________ Facility name: ________________________________________________________________________________ Address: _____________________________________________________________________________________ _____________________________________________________________________________________ Phone #__________________________Contact person at facility:________________________________________ Date (s) facility was contacted: ____________________________________________________________________ What type of resident do they serve? _______________________________________________________________ Does the facility have any vacancies?[ ] yes [ ] no Is your resident on their waiting list? [ ] yes [ ] no Est. time to reach the top of the list: __________________ Please include additional facility contacts as needed. Fax to: Office of Aging and Disability Services (207) 287-9231 Include this 2-page completed application and the 2-page Outcome Report from the medical eligibility determination (MED) assessment, done by the Departments Assessing Services Agency If the resident is admitted to a hospital, the APRC approval period ends on the date of hospital admission This form is due at least 5 (five) days before the end of the currently approved eligibility period. Please contact the Office of Aging and Disability Services at 1-800-262-2232 with any questions.      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