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FAQ
Transition Candidate Inquiry Form
Fill out the form below or
click here
to download a form to mail or fax to ADVANTAGE.
*
Date Inquiry Form Completed:
Person Completing Form's Information
*
Name:
*
Relation to Candidate:
Address of Person Filling out Form:
Street:
City:
State:
Zip:
*
Phone:
The person listed below has expressed an interest in transitioning, or in assisting a friend/relative in transitioning, from a nursing home back into the community.
Candidate's Information
*
Candidate’s Name:
*
Medicaid RID#:
Medicare #:
Information on Current Nursing Facility
*
Nursing Facility:
Street:
City:
State:
Zip:
*
Phone:
*
Number of Qualified Months in Long Term Institutional Care:
*
Candidate's Desired Living Arrangement(s):
Independent Living
Adult Foster Care
Assisted Living Facility
Home with Family
*
Does This Candidate Meet State Approved Nursing
Facility Long Term Level of Care (450B)?
Yes
No
Not Sure
If
"No,"
what date is this individual expected
to meet Long Term Level of Care?
Family or Guardian's Information
*
Is Family or Guardian Involved in the Referral Process?
Family
Guardian
No
Guardian's Name:
Address of Family or Guardian
Street:
City:
State:
Zip:
Phone:
