Florida Department of Elder Affairs: 701S Screening Form

Submit the completed 701S Screening Form to the Florida Department of Elder Affairs either via email, fax, or mail. For email submissions, send to elderservices@elderaffairs.org. For fax submissions, use the number (850) 414-2000. Mail submissions can be sent to Florida Department of Elder Affairs, 4040 Esplanade Way, Tallahassee, FL 32399-7000. It is recommended to keep a copy of your submission for your records.

Important dates for this form in 2024 and 2025 include: Initial submission deadline on January 15th, 2024; Annual assessment updates due by April 30th of each year.

The purpose of the 701S Screening Form is to collect essential information from individuals to determine their eligibility for health and social services. It helps in assessing the health conditions, living situations, caregiver involvement, and financial status of the persons seeking assistance. This form ensures that the eligible individuals receive the appropriate care and support programs offered by the Florida Department of Elder Affairs.

• 1. SCREENER: Indicates the purpose of the assessment.
• 2. Social Security number: Required for identification and program referral purposes.
• 3. Name: Includes first, middle initial, and last name.
• 4. Medicaid number: Identifier for Medicaid recipients.
• 5. Phone number: Contact number of the individual.
• 6. Date of birth: Birth date of the individual in mm/dd/yyyy format.
• 7. Sex: Selection of male or female.
• 8. Race: Options include White, Black/African American, Asian, etc.
• 9. Ethnicity: Hispanic/Latino or other.
• 10. Primary language: Languages include English, Spanish, and others.
• 11. Limited English ability: Indicates if there's a limitation in understanding English.
• 12. Marital status: Options include Married, Partnered, Single, etc.
• 13. Current Physical Location Address: Details of the current living address. If a facility, include the facility name.
• 14. Home Address: If different from current physical location, includes home address details.
• 15. Mailing Address: If different from home address, includes mailing address details.
• 16. Assessment date: Date when the assessment was conducted.
• 17. Referral date: Date when the referral was made.
• 18. Referral source: Source of the referral, such as Self/Family, Case management, etc.
• 19. Transitioning out of a nursing facility: Indicates if transitioning out of a nursing home.
• 20. Imminent risk of nursing home placement: Indicates if there's an imminent risk of nursing home placement.
• 21. Primary caregiver: Indicates if there's a primary caregiver.
• 22. Living situation: Options include living alone or with caregivers.
• 23. Individual monthly income: Monthly income of the individual.
• 24. Couple monthly income: Monthly income if part of a couple.
• 25. Estimated total individual assets: Estimated assets ranging from $0 to $6,001 or more.
• 26. Estimated total couple assets: Estimated assets of the couple.
• 27. Receiving S/NAP: Indicates if receiving food stamps.
• 28. Need other food assistance: Indicates need for additional food assistance.
• 29. Health rating: Health rating from Excellent to Poor.
• 30. Comparison to previous year health: Health comparison to previous year.
• 31. Physical problem prevention: Frequency of limitations due to physical problems.
• 32. Medical care access: Frequency of access to medical care.
• 33. Transportation to medical care: Frequency of transportation access to medical care.
• 34. Financial/insurance access to health care: Financial/insurance ability to obtain health care and medications.
• 35. Memory or cognitive impairment diagnosis: Indicates if diagnosed with memory loss or cognitive impairment.
• 36. Nursing or rehabilitation facility stay: Indicates if in a nursing/rehabilitation facility in the past year.

Failure to submit the 701S Screening Form may result in the individual not being considered for health and social services programs offered by the Florida Department of Elder Affairs.

• Program Ineligibility: Without submission, assessment for eligibility can't be done.
• Lack of Assistance: The individual may miss out on necessary care and support services.
• Delay in Services: Delays in processing due to missing information.

• 1. Initial Application: For first-time applicants seeking elderly care services.
• 2. Annual Assessment: To update information and continue receiving services.
• 3. Change in Circumstances: When there is a change in living situation or health status.
• 4. Caregiver Management: When a caregiver needs to provide information on behalf of the individual.
• 5. Program Referral: For referrals to specific programs based on eligibility.