Get the free Long-Term Services and Supports Assessments Request Form

Long-Term Services and Supports Assessments Request Form Phone 714-246-8444 Fax 714-246-8843 Fax this form to CalOptima LTSS department Requestor Info Requester Name Title Phone Number Fax Number Email HMO/Health Network Name NPI Signature Date Member Info Patient Name Date of Birth // CIN Primary Care Provider Member Eligibility Date // HMO/Health Network Name Please attach member s eligibility computer screenshot showing eligibility date and HMO/HN affiliation or a copy of signed and...

How to fill out long-term services and supports

How to fill out long-term services and supports

1. Gather all necessary documents and information needed to complete the application.
2. Ensure you meet the eligibility requirements for long-term services and supports.
3. Contact your local long-term services and supports agency for guidance on the application process.
4. Fill out the application form thoroughly, providing accurate and detailed information.
5. Attach any required supporting documents, such as medical records or proof of income.
6. Review the completed application to ensure all sections are filled out correctly.
7. Submit the application by the specified deadline.
8. Follow up with the agency to ensure your application is being processed.
9. Be prepared to provide additional information or attend an assessment if requested.
10. Keep copies of all submitted documents for your records.

Who needs long-term services and supports?

1. Individuals with chronic illnesses or disabilities that require ongoing assistance and support.
2. Elderly individuals who are unable to perform activities of daily living independently.
3. Individuals with cognitive impairments or mental health conditions that limit their ability to function independently.
4. People who have suffered severe injuries or illnesses that have resulted in long-term disabilities.
5. Individuals with progressive conditions that require long-term care, such as Parkinson's disease or multiple sclerosis.
6. Caregivers who require support in providing care to their loved ones.

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What is long-term services and supports?

Long-term services and supports refer to a range of assistance designed to help individuals with functional limitations or chronic illnesses maintain their independence and quality of life.

Who is required to file long-term services and supports?

Individuals who need assistance with daily activities due to functional limitations or chronic illnesses are required to file for long-term services and supports.

How to fill out long-term services and supports?

To fill out long-term services and supports, individuals need to provide information about their functional limitations or chronic illnesses and the types of assistance they require.

What is the purpose of long-term services and supports?

The purpose of long-term services and supports is to help individuals with functional limitations or chronic illnesses maintain their independence, quality of life, and ability to perform daily activities.

What information must be reported on long-term services and supports?

Information that must be reported on long-term services and supports includes details about the individual's medical history, functional limitations, types of assistance required, and caregiver information.