Intake and Referral Form for Social Services
This file contains the Intake and Referral form used by the Washington State Department of Social and Health Services. It provides essential information and guidance for individuals seeking long-term services and supports. Fill it out to facilitate the review and approval process for social services.
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How do I fill this out?
To complete this form, start by entering the applicant's personal information in Section 1. Next, provide the current location and Medicaid eligibility details in Sections 2 and 3. Ensure all relevant boxes are checked in Sections 4 and 5 to indicate desired services and care needs.
How to fill out the Intake and Referral Form for Social Services?
1
Gather all applicant information such as name, address, and phone number.
2
Fill out sections regarding Medicaid eligibility and current location.
3
Indicate desired settings and services the applicant is interested in.
4
Complete the nursing needs screening and personal care needs sections.
5
Provide referent information before submitting the form.
Who needs the Intake and Referral Form for Social Services?
1
Individuals applying for long-term services and supports.
2
Family members assisting a loved one in need of social services.
3
Social workers coordinating care for clients.
4
Healthcare providers recommending services for their patients.
5
Community organizations supporting individuals in navigating social services.
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What are the instructions for submitting this form?
Submit the completed Intake and Referral form by faxing it to the designated regional office associated with the applicant's location. Ensure to include all necessary information to facilitate processing. For specific fax numbers and further details, refer to the instructions provided in the form.
What are the important dates for this form in 2024 and 2025?
Important dates for the 10-570 form include submission deadlines for various services and eligibility assessments throughout 2024 and 2025. Keep an eye on regional office announcements for specific timelines. Accurate submission will help avoid delays in service initiation.
What is the purpose of this form?
The purpose of the Intake and Referral form is to facilitate access to long-term services and supports by collecting necessary information from individuals. It assists social workers and intake personnel in determining eligibility and service needs accurately. Through proper completion and submission, applicants are connected with vital services that can enhance their quality of life.
Tell me about this form and its components and fields line-by-line.
- 1. Applicant Information: Collects personal details, contact information, and social security number.
- 2. Applicant Current Location: Captures the applicant's current residence and relevant contact numbers.
- 3. Medicaid Eligibility Information: Determines the applicant's Medicaid status and related details.
- 4. Desired Setting and Services: Indicates the preferred living arrangement and services required.
- 5. Nursing Needs Screening: Assesses specific care needs and medical requirements.
- 6. Referent Information: Gathers details of the person or agency referring the applicant.
What happens if I fail to submit this form?
Failing to submit this form may delay access to important services and supports the applicant needs. It can result in missed deadlines and complications in processing assistance requests.
- Delayed Services: Failure to submit can postpone the initiation of critical long-term care services.
- Eligibility Issues: Incomplete submissions may cause complications in determining eligibility for support.
- Lack of Communication: Not submitting can hinder coordination between social services and healthcare providers.
How do I know when to use this form?
- 1. When seeking long-term care support: Utilize this form to access services for aging or disabled individuals.
- 2. For Medicaid application assistance: Complete this form to start the process of applying for Washington Apple Health.
- 3. Referral for family or clients: Use it to assist family members or clients needing coordination with social services.
Frequently Asked Questions
What is the purpose of the Intake and Referral form?
This form is designed to gather necessary information for individuals seeking long-term services and supports.
How can I edit this PDF file?
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Is it possible to share the edited PDF?
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How do I submit the completed form?
Fax the completed form to the appropriate regional office indicated in the instructions.
Can I save the changes I made?
You can download the edited document after making changes, though saving directly on the site is not available.
What should I include in Section 1?
Fill out all personal information about the applicant, ensuring accuracy.
What does Medicaid Eligibility Information involve?
You need to indicate if the applicant is on Washington Apple Health and provide the ProviderOne ID.
How do I find the regional contact information?
The contact information for each region is listed within the instructions section of the form.
What if the applicant is married?
Include the spouse's name and relationship in the relevant section.
Is there assistance available for filling out this form?
Yes, regional offices provide support and guidance if you have questions.
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