B-7440 Alternate Care Services

Revision 21-3; Effective September 1, 2021

Information about all available long-term services and supports must be provided to long term care recipients, their authorized representatives (ARs) and at least one family member of the recipient, if possible. This allows them to make an informed decision about service options.

Form H1204 , Long Term Care Options (PDF) , provides information on available long-term services and supports. It is included with the TF0001, Notice of Case Action, for all MEPD certifications, except for recipients residing in state supported living centers, state hospitals and state centers.

If an applicant, recipient, AR or family member(s) has questions about available long-term care services, refer them to 2-1-1 for current information.

Form H1746-A , MEPD Referral Cover Sheet (PDF) , includes an "LTSS Information Shared" checkbox. Referring agencies will select the box to indicate that Form H1204 has been shared with the person.

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B-7440 Alternate Care Services

Official source

Revision 21-3; Effective September 1, 2021

Information about all available long-term services and supports must be provided to long term care recipients, their authorized representatives (ARs) and at least one family member of the recipient, if possible. This allows them to make an informed decision about service options.

Form H1204 , Long Term Care Options (PDF) , provides information on available long-term services and supports. It is included with the TF0001, Notice of Case Action, for all MEPD certifications, except for recipients residing in state supported living centers, state hospitals and state centers.

If an applicant, recipient, AR or family member(s) has questions about available long-term care services, refer them to 2-1-1 for current information.

Form H1746-A , MEPD Referral Cover Sheet (PDF) , includes an "LTSS Information Shared" checkbox. Referring agencies will select the box to indicate that Form H1204 has been shared with the person.