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California Department of Aging, Multipurpose Senior Services Program SSP Site Manual Appendix 11a Request for eInstitutional Services SSP Site Applicant's Name Medical # Telephone Phone Street Address

How to fill out request for deinstitutionalization services

How to Fill Out a Request for Deinstitutionalization Services:

1. Begin by obtaining the necessary forms. Contact your local government agency or healthcare provider to request the specific forms for requesting deinstitutionalization services. These forms may include personal information, medical history, and reasons for seeking deinstitutionalization.
2. Review the forms carefully. Take the time to read through each section of the forms and understand the information that is required. Pay attention to any specific instructions or guidelines provided.
3. Provide personal information. Start by filling out your name, address, contact number, and any other requested personal details. Ensure that all the information provided is accurate and up to date.
4. Explain the reasons for seeking deinstitutionalization. In a separate section or through follow-up questions, describe the specific reasons why you are seeking deinstitutionalization. This may include dissatisfaction with current institutional care, a desire for more independence and community integration, or medical/psychological assessments indicating that deinstitutionalization would be beneficial.
5. Include any relevant medical or psychiatric history. Fill out any sections related to medical or psychiatric history, including diagnoses, current medications, treatments, and any previous hospitalizations or institutionalizations.
6. Attach supporting documents. If you have any supporting documents such as medical reports, assessments, or recommendations from healthcare professionals, make copies and attach them to your request. These documents can strengthen your case for deinstitutionalization.
7. Provide contact information for your healthcare provider. Include the name, address, and contact information of your current healthcare provider who will coordinate your care during the deinstitutionalization process. This will allow the appropriate professionals to communicate and collaborate on your transition plan.

Who Needs a Request for Deinstitutionalization Services?

1. Individuals receiving long-term institutional care: People who are currently residing in nursing homes, psychiatric hospitals, rehabilitation centers, or other long-term institutional care facilities may need to complete a request for deinstitutionalization services if they wish to transition to community-based services.
2. Family members or guardians: In some cases, the request for deinstitutionalization services may be initiated by a family member or legal guardian who believes that their loved one would benefit from living in a less restrictive environment.
3. Healthcare professionals: Healthcare professionals, including doctors, psychiatrists, social workers, or case managers, can also play a vital role in initiating and supporting a request for deinstitutionalization services. They may assist in completing the necessary forms, providing relevant medical information, and advocating for the individual's transition to community-based care.

Note: The specific criteria for deinstitutionalization services may vary depending on the jurisdiction and the type of care facility. It is important to consult with local healthcare authorities or professionals to ensure that you are following the appropriate process for your situation.

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What is request for deinstitutionalization services?

Request for deinstitutionalization services is a formal application made by an individual or their representative to seek the transition of a person from an institutional setting to community-based services and supports.

Who is required to file request for deinstitutionalization services?

The request for deinstitutionalization services can be filed by the individual themselves, their legal guardian, or a designated representative authorized to make decisions on their behalf.

How to fill out request for deinstitutionalization services?

To fill out a request for deinstitutionalization services, one must provide personal information, relevant medical history, reasons for seeking deinstitutionalization, and details of the desired community-based services and supports.

What is the purpose of request for deinstitutionalization services?

The purpose of the request for deinstitutionalization services is to facilitate the transition of individuals from institutionalized settings to community-based services that promote independence, inclusion, and quality of life.

What information must be reported on request for deinstitutionalization services?

The request for deinstitutionalization services must include personal information, medical history, reasons for seeking deinstitutionalization, desired community-based services, and any supporting documentation that may be relevant.

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