ࡱ> _a^q  bjbjt+t+ .dAA ]8d\::::v " < $t n r t t l::4lllt l::t ll,:$ü^^New Jersey Department of Human Services Division of Aging Services Assisted Living/Adult Family Care (AL/AFC) Referral FOR THE GLOBAL OPTIONS FOR LONG-TERM CARE (go) MEDICAID WAIVER APPLICANT BACKGROUND INFORMATIONName of Applicant (First, Middle Initial, Last)  FORMTEXT      Social Security Number  FORMTEXT      Street Address  FORMTEXT      Date of Birth  FORMTEXT      City, State, Zip Code  FORMTEXT      Telephone Number  FORMTEXT      Medicaid Application Filed at CWA?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoCounty of Application  FORMTEXT      Caregiver/Legal Representative  FORMTEXT      Telephone Number  FORMTEXT      Referring AL/AFC Provider  FORMTEXT      Telephone Number  FORMTEXT      Reason for Referral  FORMCHECKBOX  Spend Down  FORMCHECKBOX  New AdmitNOTE: The processing of the AL/AFC Referral Form does not constitute enrollment on the GO Medicaid Waiver nor does it guarantee residency for the applicant at the referring AL/AFC facility.APPLICANT CLINICAL INFORMATIONDiagnosis  FORMTEXT      Check off the level of assistance the applicant requires for EACH Activity of Daily Living (ADL):Activities of Daily Living (ADL)IndependentSupervision/ CueingLimited Assist or GreaterCognitive StatusIntactImpairedShort Term Memory FORMTEXT       FORMTEXT      Bathing FORMTEXT       FORMTEXT       FORMTEXT      Procedural Memory FORMTEXT       FORMTEXT      Dressing FORMTEXT       FORMTEXT       FORMTEXT      Decision Making FORMTEXT       FORMTEXT      Bed Mobility FORMTEXT       FORMTEXT       FORMTEXT      GO Waiver Target Population CriteriaEating FORMTEXT       FORMTEXT       FORMTEXT      Aged 65+, or Physically Disabled Age 21-64  FORMCHECKBOX Yes  FORMCHECKBOX NoLocomotion  FORMTEXT       FORMTEXT       FORMTEXT      Toilet Use FORMTEXT       FORMTEXT       FORMTEXT      Age 21-64 with MR/DD/Chronic MI FORMCHECKBOX Yes*  FORMCHECKBOX NoTransfer FORMTEXT       FORMTEXT       FORMTEXT      * If Yes, the applicant is ineligible for GO and the AL facility is to counsel the applicant on other options.Other Care Needs  FORMTEXT      Social Information/Family Supports  FORMTEXT      APPLICANT FINANCIAL INFORMATIONMonthly IncomeResources (bank accounts, stocks, bonds, etc.)Social Security FORMTEXT       FORMTEXT      Pension FORMTEXT       FORMTEXT      Other FORMTEXT       FORMTEXT      Total Monthly Income FORMTEXT       FORMTEXT      Face Value of Life Insurance Policy(ies), if known: FORMTEXT      Name of Individual Completing Form (Print)  FORMTEXT      Title  FORMTEXT      Signature Date  FORMTEXT           AL-6 JUL 12Note: If applicant is found eligible for the GO Medicaid Waiver, there may be a cost share to the applicant, which is dependent on his or her income and allowable deductions. 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