Structure
The Wisconsin F 00366 form serves as a crucial instrument in assessing the eligibility of individuals seeking long-term care services within the state. Designed by the Department of Health Services, this form facilitates the initial functional screening process for adults requiring assistance due to various health conditions. It captures essential information about the applicant, including their name, date of birth, and social security number, which are vital for establishing identity and eligibility. Additionally, the form requires details about the screener and the referral source, ensuring that the screening process is thorough and well-documented. It categorizes applicants based on their specific needs, such as physical disabilities, developmental disabilities, or cognitive impairments like Alzheimer’s disease, thereby helping to identify the appropriate care pathways. The F 00366 also addresses the applicant's current living situation and the expected duration of their condition, which is significant in determining the level of care required. By systematically gathering this information, the form plays a pivotal role in connecting individuals with the necessary services and support, ultimately promoting better health outcomes for Wisconsin’s adult population in need of long-term care.
Form Example
Document Specs
| Fact Name | Details |
|---|---|
| Form Purpose | The Wisconsin F-00366 form is used for conducting functional screenings for adults seeking long-term care services. |
| Governing Law | This form is governed by Wisconsin state laws pertaining to long-term care and Medicaid services. |
| Screen Types | The form allows for two types of screenings: Initial Screen and Rescreen, ensuring flexibility based on the applicant's needs. |
| Applicant Information | Essential details such as the applicant's name, date of birth, and Social Security number are required for identification purposes. |
| Referral Sources | The form identifies various referral sources, including self-referrals, family members, and healthcare professionals, to ensure comprehensive support. |
| Target Group Identification | Applicants must indicate if they belong to specific target groups, such as those with disabilities or terminal conditions, to facilitate appropriate care. |
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