Please read the following information concerning this Intake Form and Complaint/Grievance Procedure:
We are asking you to complete the attached form to the best of your knowledge so we understand how you would like to receive services. Some basic information (*) is needed to meet compliance with federal and state reporting requirements and to target consumers age 60 and older who have the greatest economic and social need, such as individuals who are low-income minority, frail, and rural. Requests for services are processed as funds allow.
Your income level is not used to qualify you to receive services, but rather as a means to gather demographic data to various entities to show the need for continued funding of services. Nobody will contact you unless you choose so in order to receive information about services which might be available to you.
If there is not enough room on the application for any of your responses, please attach a separate sheet.
The purpose of the Complaint/Grievance/Appeal Procedure is
• To ensure fair and equitable treatment of all consumers, eliminate dissatisfaction, resolve problems and
• To establish complaint and appeals procedures that inform the consumers of their rights to complain and receive a written response at the provider level
Any OAA/OCA (Older Americans Act/Older Coloradans Act) eligible consumer who has a complaint/grievance with the organization asking you to fill out this assessment form has the right to file a complaint/grievance with said organization. The written grievance or appeal will be reviewed by the provider's Program Coordinator and the Douglas County Adult Services Program Manager, who will have ten business days to review the grievance or appeal and respond in writing to the client. If not satisfied with the organization’s decision, to appeal that decision with either the local AAA (Area Agency on Aging) or the SUA (State Unit on Aging).
The complete Complaint/Grievance/Appeal Procedure is available upon request by contacting your local AAA and/or the SUA as follows:
Office of Community Access and Independence
Aging and Adult Services
1575 Sherman Street, 10th Floor
Denver, CO 80203
(303) 866-2800 (Main Line) (303) 866- 2977 (Fax) (888) 866-4243 (Toll Free)
Any person receiving services shall have the opportunity to contribute towards the cost of the service. No eligible person shall be denied a service because of their inability and/or choice not to contribute.
Instructions about filling out the 2018 Basic Consumer Intake Form:
This Basic Consumer Intake From is provided as a courtesy to allow the AAAs and their providers to gather the information required by the federal or state government to be entered into Colorado’s official data system (currently PeerPlace). If this information is already obtained by other means, there is no need to fill this Basic Intake Form out again, as long as you have the data to register a client in PeerPlace, by entering the starred (*) data elements into the detailed consumer record.
(*) Any fields with this prefix designate demographic data collected by the federal or state government to support the need for continued funding for the various programs. This data will be de-identified and used in aggregate form to compile statistical information. None of the data is sold to a third party and any personal information will only be used in an effort to better serve the client in providing him/her with services.
There is one additional required field you need to be aware of, which is not on the form but needs to be checked in the Financial section under Client Information when you enter the Basic Consumer Intake into PeerPlace. That field is ‘Is the client’s income level below the national poverty level?’ Please check “Yes”, if either the question above about the monthly individual or household income is answered with “Yes”; mark ‘No’ otherwise.
Any fields which do not have the (*) prefix are optional, but help determine in what other ways we might be able to help the client and to get feedback about which of our outreach programs are successful. Please try to obtain as much information as possible, since we can only help when we know that there is a need.
While we ask you to make an honest effort to gather this basic information, we cannot deny services to clients on the basis of them refusing to provide the requested information, as our programs are not means tested. Since our programs are specifically for the elderly, particularly for persons age 60 or over, the date of birth needs to be filled in. If the client refuses to provide his/her date of birth, please enter 01/01/1901. Then, indicate in the General Comments “client refused to provide DOB, so the default date was entered”.
This form may be used for the following workflows (any other workflow requires one of the available assessment forms, rather than just a basic intake):
• Assisted Transportation/Escort
• Health Promotion
• Information and Assistance (if this is entered as an aggregate, no basic intake or registration is needed)
• Material Aid
• Nutrition Education (if this is entered as an aggregate, no basic intake or registration is needed)
• Other (service type Screening always needs a basic intake, Education may be entered as aggregate, in which case no basic intake or registration is needed)
If you have any questions, please contact your local AAA office.