Lee County Central
Point of Coordination Application
Return Application Requested By:___________________ HIPPA Yes___NO___
Name of Applicant:_______________________________________________________
Last First M.I.
City
State Zip County
Parent Name (If applicant is under
18 years of age)
_____________________________ _______________________________________
Name Address
Ethnicity:
1) White, not Hispanic _____ 2) African American _____
3) Native American _____4) Asian or Pacific Islander _____
5) Hispanic _____ 6) Other (Biracial, Indochinese etc.) _____
Guardian:(name)____________________
Conservator:(name)____________________
Payee:(name)____________________________________________________________
Veterans of US Armed Forces:
Yes _____ No _____
Marital Status:
1) Single, never married ____2) Married ____3) Divorced ____
4) Separated ____ 5)Widowed ____
Legal Status:
Voluntary:________ Involuntary, Civil Commit:_________
Involuntary, Criminal
Commit: _________
1) Lives alone _____ 2) Lives with relatives _____
3) Lives with persons unrelated to applicant _____
Disability Group (primary diagnosis): (40)Mental Illness ______ (41)Chronic Illness______
(42)Mental Retardation ________ (43)Developmental Disabilities _________
Other:___________________________________________________
Referred By:
1)Self _____ 2) Family Member _____ 3) Case Management _____
4) Community Corrections _____5) Social Services other than Case Management _____
6) Other_____
Years of Education: (High School or GED) ______ College
Years Completed: _____
Health Insurance: (Indicate all that apply)
1) Insured by Employer __________ 2) Other Private Insurance __________________
Name of Insurance Provider _______________________________________________
3) Medicare _________
4) Medicaid __________________Medicaid (Title XIX)#________________________
5) No Insurance _________ 6) Other (explain)______________________
Current Employment Status:
Unemployed, available for work _______
Student ______
Unemployed, unavailable for work _______
Work Activity Employment ______
Employed, full time _______
Sheltered Work Employment ______
Employed, part time _______
Vocational Rehabilitation ______
Retired _______
Armed Forces ______
Homemaker _______
Primary Income Source:
Family and Friends ______
Private Relief
Agency ______
SSDI ______
SSI ______
SS ______
Pension ______
Food Stamps ______
Veterans Benefits ______
Workers Comp. ______
General Assistance ______
FIP ______
Do You Rent Your Home: Yes ______ No_______
Do You Own Your Home: Yes_______ No_______
Number of Persons Residing In Your Household:
Adults:_________ Persons Under
18:__________ Household Total:_____________
Names of Persons Residing In Your Household, Including
Yourself:
Name:________________________________
Relationship:________________
Name:________________________________ Relationship:________________
Name:________________________________ Relationship:________________
Name:________________________________ Relationship:________________
Name:________________________________ Relationship:________________
Monthly Gross Income for the Household:
Place of Employment
___________________________________________________
Employment Wages Per Hour $ ___________
Number of Hours Worked Each Week ___________
Total Monthly Wage $____________
Public Assistance $________
Social Security $________
V.A. Benefits $________
S.S.I. $________
Child Support $________
S.S. D. I. $________
Dividend Interest $________
Other Income $________ Income Description_______________________
Total Monthly Income
$___________________
Resources:
Cash on Hand $___________ Checking $__________ Savings $_______
Time Certificates $___________ Trust Funds $__________ Stocks/Bonds $_______
Other Resources $___________ Resource Description ______________________
Other Resources $___________ Resource Description ______________________
Total Resources $___________
Do you have a Case Manager: No _______ Yes_______ Name _________________
Do you have an Income Maintenance Worker: No_____ Yes ____ Name ____________
Who is your
Beneficiary:__________________________________________________
Address:_______________________________________ Phone:___________________
Do you have life insurance or pre-burial arrangements paid: Yes_______No_________
Have you applied for
Social Security Disability: Yes _________ No _____________
Have you received
General Relief in the past: No ______Yes_____ Where________
Employment History:
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Legal Settlement:
Note:
List all previous addresses up to the point where you lived at an
address for three hundred and sixty five days consecutively
without
receiving any services for mental illness, mental retardation
and/or
developmental disabilities.
Use addition paper if needed.
Please list where you have lived in the past, begin with your current address.
Current Address: ___________________City
What dates have you lived at this address? From:________To:__________
Did you receive treatment or support services for Mental Illness, Mental Retardation
or Developmental Disabilities while at this address? Yes ____ No____ (If yes)
What were the dates? From: _____________ To: _____________
Where were services provided:____________________________________
Previous Address: _________________________City
What dates did you live at this address? From: _____________To: __________
Did you receive treatment or support service for Mental Illness, Mental Retardation
or Developmental Disabilities while at this address? Yes _____ No____(If yes)
What were the dates? From: _____________ To: ______________
Who provided your service(s):______________________________________________
Previous Address: __________________________City
What dates did you live at this address? From: _______________To: _______
Did you receive treatment or support service for Mental Illness, Mental Retardation
or Developmental Disabilities while at this address? Yes _____ No____(If yes)
What were the dates? From: _____________ To: ______________
Who provided your service(s):_____________________________________________
Previous Address: __________________________City
What dates did you live at this address? From: _______________To: ______________
Did you receive treatment or support service for Mental Illness, Mental Retardation
or Developmental Disabilities while at this address? Yes _____ No____(If yes)
What were the dates? From: _____________ To: ______________
Who provided your service(s):_________________________________________________
Signature: I hereby state that the above information is
accurate to the best of my
knowledge. I understand that I may be liable for the
full cost of services provided to me,
which were paid based on
inaccurate information, which I may have supplied.
Release: I hereby authorize the Lee County Central Point of Coordination Office designee to
request any and all information to
verify the application data. The applicant has a right to
appeal the decision of the Central Point of
Coordination Office by writing a letter requesting an
appeal within 30 days of the issuance of the notice
of decision concerning that action. The appeal
form may be obtained from the Central Point of
Coordination Office,
national origin or political belief.
Consumer/Guardian Signature:__________________________
Date:_____________
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ACKNOWLEDGMENT OF RECEIPT
OF NOTICE OF PRIVACY PRACTICES
I,_______________________________________,
do hereby acknowledge receipt of a
copy of the Notice of Privacy Practices, Policies, and
Procedures.
____________________________________________________________________
Signature of Individual
_______________________
Date
In the event this request
is made by the individual’s personal representative:
____________________________________________________________________
Signature of Legal
Authority of
Personal Representative Personal Representative
_________________________
Date
The HIPAA Notice of Privacy
Practices Brochure is accessible via the web at:
Leecounty.org
Approved: ___________ Denied:___________ Pending:___________
Approved
for:
State Case Funding_______________________
(
Primary Diagnosis: MI________ CMI_________MR_________DD_________
If denied, reason for this denial is:
No Legal Settlement _______
Income Over Guidelines _______
Other Insurance Coverage _______
Resources Over Guidelines _______
Other _______
Explanation: ____________________________________________________
Signature of Person Issuing Notice: _______________________ Date: ______________
Lee County Central Point of Coordination Office
(319)-372-5681 or Fax: (319)-372-8921