Forms include program applications, documents and assessment tools used to administer each program managed by ASD
Adult Day Services Forms
- Adult Day Health Rehab Services Prior Authorization Form
- Adult Day Health Rehab Services Prior Authorization Form: INSTRUCTIONS
Adult High Technology Program Forms
ARIS Solutions Employer Payroll Services Forms
- ARIS Solutions Employer Payroll Services Forms
- ARIS Website - Employer & Employee Enrollment Forms
- Employer Certification Form
- Moderate Needs Flexible Funds Enrollment & Change Form
Assessment Tools
(NOTE: Users of OMNIA/SAMS complete assessments electronically.)
- Independent Living Assessment Health Review Section
- Home Based Full Independent Living Assessment
- Independent Living Assessment (ILA) - Intake Only
- ILA Manual - FULL
- ILA Manual - Intake Only
- Independent Living Assessment (ILA) - Adult Family Care (AFC)
- Independent Living Assessment - TBI
- Resident Assessment - ERC
- Resident Assessment - Instructions
Attendant Services Program Forms
Choices for Care (High/Highest) Program Forms
- CFC 202LTC Application for Choices for Care Long-Term Care Medicaid
- CFC 700 Adult Family Care Tier Score Sheet
- CFC 706 Adult Family Care Referral Form
- CFC 708 AFC Home Tier Variance Request Form
- CFC 804 Forms Instructions
- CFC 804 Admission to Services Form
- CFC 804A Termination of Services
- CFC 804B Nursing Home Change of Payment
- CFC 804C Short-Term Medicaid Only Rehab Form
- CFC 804D Dual Rehab Form
- CFC 805A HB GDAC Service Plan
- CFC 805B Enhanced Residential Care Service Plan
- CFC 805D Adult Family Care Service Plan
- CFC 808 Shared Living Agreement Template and Requirements
- CFC 809 Emergency Contacts & Backup Plan
- CFC 810 High Needs Wait List Score Sheet
- CFC 811 High Needs Wait List Follow-up Sheet
- CFC 813A Variance Request Form
- CFC 813B Regulation/Policy Variance Request Form
- CFC Options at a Glance
- ERC Tier Worksheet
- Hospice Notification Form
- Critical Incident Reporting Form
- Mission Care at Bennington Referral Form
Moderate Needs Program Forms
- CFC 900 Moderate Needs Group Application
- CFC 901 Moderate Needs Group Clinical Eligibility Worksheet
- CFC 902 Moderate Needs Financial Eligibility Worksheet
- CFC 903 Moderate Needs Service Request
- CFC Moderate Needs Wait List
- CFC 904 Moderate Needs Termination
- CFC 905 Moderate Needs Checklist
- CFC 906 Moderate Needs Flexible Funding Worksheet
- Moderate Needs Complete Package
- Moderate Needs Flexible Funds Monthly Report Form
Money Follows the Person Forms
- MFP Referral Form
- MFP Informed Consent
- MFP Information Release
- MFP Authorization to Release Personal Testimonial