MN Department of Human Services, Office of Inspector General Licensing Division, 245D HCBS Form
Service Recipient Information Cover Sheet
Person Information
Name
*
First name
Last name
Admission Date
/
Month
/
Day
Year
Date
Service Initiation Date
/
Month
/
Day
Year
Date
Date of Birth
*
/
Month
/
Day
Year
Date
Gender
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Social Security Number
*
Waiver Type
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
Service Type:
*
24-hour Emergency Assistance
Adult Companion Services
Homemaker
Night Supervision
Respite Care, in home or out-of-home
Individual Community Living Support (ICLS)
Individualized Home Supports (IHS)
Other
Legal Status
*
Responsible for Self
Under Guardianship
Under Commitment
Insurance Information
Medical Assistance Number
*
Primary Insurance Number
Medicare Number
Other Insurance Information
Legal Representative Contact Information
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Emergency Contact Information
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Case Manager Contact Information
Name
*
First name
Last name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Format: (000) 000-0000.
Health Information
Medical History
Special Dietary Needs
Allergies
Health Care Provider Contact Information
Primary Physician
First Name
Last Name
Clinic Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Clinic Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
This program is responsible for assisting this person in setting up medical appointments:
*
Yes
No
Other Service Providers
Contact Person
Services Provided
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Consent and Signatures
HIPAA & Data Privacy Compliance: I understand that Aurora Home Health INC. will maintain confidentiality of my records in compliance with HIPAA and 245D regulations. My information will only be shared as required for service provision or as permitted by law.
*
I consent to the release of necessary information for service coordination.
Date
*
-
Month
-
Day
Year
Date
Client Name
*
First Name
Last Name
Client Signature
*
Legal Representative Name
First Name
Last Name
Legal Representative Signature
Please verify that you are human
*
Continue
Continue
Should be Empty: