Mapping out the form 620 is a necessary step in completing this document. By understanding the required information and how it is to be submitted, you can avoid common mistakes and ensure a smooth process. The form 620 is used to report international sales of property by U.S. persons to foreign individuals or entities, so it is important to understand all of the requirements before starting the submission process. Knowing where to find the specific information and what formatting is required will help make the task less daunting. Reviewing previous submissions can also provide helpful insight on what works well and what could be improved. Taking these steps will ensure that your form 620 filing is accurate and complete.
| Question | Answer |
|---|---|
| Form Name | Form Map 620 |
| Form Length | 4 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 1 min |
| Other names | scl_app scl waiver and icfmr services form map 620 |
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Page 1 |
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APPLICATION FOR SCL WAIVER AND ICF/MR SERVICES |
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Read attached instruction sheet before completing this application |
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Section 1 |
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Sex: M |
or F |
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Name: |
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First |
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Middle |
Last |
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Social Security Number |
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Medical Assistance Number |
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Date of Birth |
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Phone #: |
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( ) - |
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month |
day |
year |
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Present Address: |
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street |
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KY |
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city |
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County |
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State |
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Zip Code |
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Section 2
Legal Representative/Guardian
Address
KY
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city |
County |
State |
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Zip Code |
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Phone |
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Relationship to Applicant |
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(Ex: mother, father, friend) |
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Legal Rep./Guardian Signature |
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Date |
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Case Management Provider Name And Address
Name:
Address:
Section 3
City |
County |
State |
Zip Code |
Phone Number |
Section 4
DSM Diagnosis:
Axis I (Mental Health):
Axis II (Mental Retardation/Developmental Disability):
Axis III: (Physical Health):
Age Disability Identified:
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SCL Waiver |
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Physician/QMRP Signature |
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Date |
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ICF/MR |
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CMHC MR/DD Director Signature |
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Date |
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Section 5 |
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Applicant’s Signature |
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Date |
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Page 2 |
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PLEASE TELL US BOUT THE APPLICANT BY CHECKING ONE BOX UNDER EACH HEADING. |
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6. MOBILITY |
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7. COMMUNICATION |
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Walks independently |
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Speaks and can be understood |
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Walks with supportive devices |
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Speaks and is difficult to understand |
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Walks unaided with difficulty |
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uses gestures |
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Uses wheelchair operated by self |
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Uses Sign language |
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Uses wheelchair & needs help |
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Uses communication board or device |
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No mobility |
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Does not communicate |
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Comments |
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Comments: |
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8.HOW MUCH TIME IS REQUIRED FOR ASSURING SAFETY?
Requires less than 8 hours per day on average Requires
Requires 24 hours (does not require awake person overnight Requires 24 hours with awake person overnight
Extreme Need: Requires 24 hours, awake person trained to meet individual’s particular needs; continuous monitoring
COMMENTS:
9.HOW MUCH ASSISTANCE IS NEEDED FOR DAILY LIVING TASKS (Choose only ONE box)
No assistance needed in most
Minimal assistance (use of verbal prompts or gestures as reminders) needed in some
Minimal to complex assistance needed to complete complex skills such as financial planning and health planning
No assistance in some
Minimal assistance for many skills, and
Complete assistance (caregiver completes all parts of task) needed in some basic skills and all complex skills.
Partial (use of hands on guidance for part of task) to complete assistance needed in most areas of
Cannot complete complex skills.
Partial to complete assistance is needed in all areas of
Extreme need: All tasks must be done for the individual, with no participation from the individual
Page 3 |
10. HOW OFTEN ARE DOCTOR VISITS NEEDED?
For routine health care only / once per year
Extreme need: Chronic medical condition requires immediate availability and frequent monitoring
COMMENTS:
11. HOW OFTEN ARE NURSING SERVICES NEEDED?
Not at all
For routine healthcare only
Extreme Need: Several times daily or continuous availability
COMMENTS:
12. ARE THERE BEHAVIORAL PROBLEMS? |
Yes |
No
IF
Aggressive toward others
Inappropriate sexual behavior
Property destruction
Life threatening (threat of death or severe injury to self or others)
Take prescribed medications for behavior control
PLEASE CHECK ONE ANSWER UNDER EACH QUESTION, UNLESS OTHERWISE INDICATED
13 WHERE IS THE INDIVDUAL CURRENTLY LIVING?
Living with family/relative
Group home or personal care home ICF/MR (Intermediate Care Facility)
Living in own home or apartment Nursing Home
Living with a friend
Foster Care
Psychiatric Facility
Other:
14DOES THE INDIVIDUAL CURRENTLY RECEIVE ANY OF THE FOLLOWING SERVICES? (CHECK ALL THAT APPLY)
Supported Living
Medicaid Acquired Brain Injury
Supported Employment
Home Health
Other Medicaid Services
Day Program
School
Behavior Support
Transportation
Speech Therapy
Physical Therapy
Medicaid EPSDT (if under 21)
Medicaid Home & Community Based Waiver Mental Health Counseling or Medication for a mental health condition
In home support Residential Respite Occupational Therapy Case Management Other
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15 WHAT SERVICES ARE NEEDED NOW OR IN THE FUTURE?
Day Program
School
Respite
Transportation
Speech Therapy
Physical Therapy
In home support Residential Behavior Support Occupational Therapy Case Management Supported Employment
16THE FOLLOWING ARE 5 CHOICES FOR FUTURE LIVING ARRANGEMENTS. WHERE WOULD THE APPLICANT PREFER TO LIVE IN THE FUTURE? CHOOSE ONLY ONE (1):
At home with a family member with someone to come in and help
In the person’s own home with minimal support
In a 24 hour staffed residence in the community
In a 24 hour supervised family home in the community
In a 24 hour staffed group home in the community
In an ICF/MR
17 WHO IS THE PRIMARY CAREGIVER? (If staff, do not answer questions 18 & 19)
Mother |
Father |
Grandmother |
Grandfather |
Aunt |
Sister |
Brother |
Friend |
Neighbor |
Other: Who? |
18 WHAT IS THE AGE OF THE PRIMARY CAREGIVER
Uncle
Staff
Less than 30 years old
19 THE PRIMARY CAREGIVER’S HEALTH STATUS COULD BE CLASSIFIED AS:
Poor |
Stable |
Good |
Very Good |
COMMENTS:
Person Completing this Application
Print Name
Relationship to Individual (if not individual)
Phone Number
Signature |
Date |
Additional Comments:
Mailto: The Division of Mental Retardation, 100 Fair Oaks Lane,