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DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance F-62548 (01/2015) STATE OF WISCONSIN ASSISTED LIVING FACILITY WAIVER, APPROVAL, VARIANCE OR EXCEPTION REQUEST Completion of this form is

How to fill out assisted living facility request

How to fill out an assisted living facility request:

1. Gather necessary information: Before filling out the request, collect important information such as the name of the person needing assistance, their contact details, medical history, and any specific requirements they may have.
2. Contact the facility: Reach out to the assisted living facility you are interested in to request an application or intake packet. They will guide you through the process and provide the necessary forms.
3. Read the instructions: Carefully read through the instructions provided with the request forms. Make sure you understand each section and any additional documentation required.
4. Complete personal details: Begin by filling out the personal details section, including the individual's full name, birth date, address, phone number, and emergency contact information.
5. Provide medical information: In the form, there will be a section to provide the person's medical history, including any chronic conditions, allergies, medications, and doctor's contact information. Be thorough but concise.
6. Specify preferences: Assisted living facilities often offer various services and amenities. Use the request form to indicate specific preferences, such as private or shared accommodation, dietary requirements, mobility assistance, or any other preferences important to the individual.
7. Attach supporting documents: If the request form requires supporting documentation, such as medical records or financial statements, make sure to include them along with the application. Check that all documents are current and accurate.
8. Review and proofread: Before submitting the request, review all the information provided. Double-check for any missing or incorrect details. Proofread the form for any spelling or grammar mistakes.
9. Submit the request: Once you are confident that the request form is complete and accurate, follow the instructions provided to submit it to the assisted living facility. This may involve mailing, emailing, or hand-delivering the form.

Who needs assisted living facility request?

1. Elderly individuals: Senior citizens who require assistance with daily activities and personal care may need to submit an assisted living facility request. This could be due to limited mobility, chronic health conditions, or the need for social interaction and support.
2. Individuals with disabilities: People with disabilities, both physical and cognitive, may benefit from the services provided by assisted living facilities. These facilities offer specialized care and support tailored to meet the unique needs of individuals with disabilities.
3. Family members or caregivers: In some cases, family members or caregivers may need to submit an assisted living facility request on behalf of someone who is unable to do so themselves. This could be due to their cognitive or physical limitations.
4. Individuals seeking respite care: Assisted living facilities also offer short-term respite care services, providing temporary relief for family caregivers. These individuals may need to submit a request to temporarily admit their loved one into the facility during their absence.
5. Those in need of additional support: Individuals who struggle with daily tasks or cannot live independently may require the services and support offered by assisted living facilities. This can include individuals recovering from surgery or those with limited mobility or chronic health conditions.

Remember, the specific requirements for requesting assistance from an assisted living facility may vary. It is crucial to consult with the facility directly and follow their instructions to ensure a smooth application process.

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What is assisted living facility request?

Assisted living facility request is a formal application made by an individual or entity to request services or accommodations in an assisted living facility.

Who is required to file assisted living facility request?

Any individual or entity seeking services or accommodations in an assisted living facility is required to file an assisted living facility request.

How to fill out assisted living facility request?

Assisted living facility request can be filled out by providing all required information and submitting it to the appropriate facility or governing body.

What is the purpose of assisted living facility request?

The purpose of assisted living facility request is to formally request services, accommodations, or information from an assisted living facility.

What information must be reported on assisted living facility request?

Assisted living facility request must include basic personal information, desired services or accommodations, and any relevant medical or financial information.