overyceRdness anlleWgnPromotiNursing FacilityCommunity TransitionResource Packet
The following programs were created to help people who would like to transition from nursing homes.You or your legal guardian can fill out the forms in this packet to apply for these programs. In this packet,you will also find a page with more information about each of these programs. If you have questions orneed help applying, please contact any of the contact numbers listed below. Residential State Supplement: An OhioMHAS program that provides financial assistance to helpindividuals interested in living in Adult Care Facilities (ACF’s). Eligible individuals must be at leastage 18 and eligible for Medicaid. For more information, please go onlineto www.mha.ohio.gov/RSS, send an email to [email protected], or call (614) 752-9316. Recovery Requires a Community: An OhioMHAS program that provides short-term financialassistance for housing, utilities, start-up goods and services, or other recovery supports on acase-by-case basis. For more information, please go online to www.mha.ohio.gov/RRAC,email [email protected], or call (614) 644-0617. HOME Choice: An Ohio Department of Medicaid program that helps individuals transition tohome and community-based settings, where they receive services and supports. For moreinformation, please go online to www.medicaid.ohio.gov/HOMEchoice,email HOME [email protected], or call 1-888-221-1560.
Helping Ohioans choose housing options other than nursing homesHOME Choice providesassistance with moving intothe community. The personmust be in an institutionalsetting at least 90 days andmeet other eligibility criteria.Some areas of assistance Locating housing Setting up a household Connecting to necessary goods and servicesFor more information or to applyCALL (888) 221-1560The Residential State SupplementProgram provides financialassistance to adults with disabilitieswho can live in eligible communityhousing. The person must beenrolled in Medicaid and receivingSocial Security, SSI or SSDI.The RSS benefit helps pay for . . . Accommodations Supervision PersonalCare ServicesFor more information or to applyCALL (614) 752-9316or visit online:http://medicaid.ohio.gov/HomeChoiceRecovery Requiresa Communityassists people witha behavioral healthdiagnosis to moveto and remain incommunity housing. It pays for . . . temporary housing or utility assistance,or goods and servicesFor more information or to applyCALL (614) 644-0617or visit online:http://mha.ohio.gov/RSSMedicaid waivers allowindividuals with disabilitiesand chronic conditions toreceive care in their homesand communities ratherthan in long-term carefacilities. These waivers also allow individuals to havemore control over their care and remain active in theircommunities. To learn about eligibility and coverage,or to applyCALL (800) 324-8680 or (844) 644-6582or visit online:https://benefits.ohio.gov/ltssor visit online:http://mha.ohio.gov/RRACOther helpful resourcesAdvocacy/RightsHousingJob AssistanceLegal 282-9181Department of Aging OmbudsmanHousing LocatorOhio Means JobsDisability Rights OhioMental Health andAddiction Services877-275-6364 Ohio Department of Mental Healthand Addiction ServicesCounty ADAMHS Board DirectorySSI/SSDI Application 614-280-1984 SSI Ohio ProjectPublished by the Ohio Department of Mental Health and Addiction Services, Bureau of Pre-Admission Screening and Resident Review, January 2018
Residential State Supplement(RSS) Program ApplicationApplicant Name(Last, First)SSNDate SubmittedReferral SourceName/OrganizationRelationship toApplicantCounty of ReferralDOBReferral SourcePhone/Fax/Email1) Is the Applicant: (check the appropriate boxes)a) Age 18 or older? Yes Nob) Enrolled in Medicaid (not a waiver program)? Yes Noc) Currently receiving Social Security, SSI, or SSDI? Yes Nod) Currently receiving treatment in a nursing facility? Yes No Yes Nof) A veteran of the U.S. Military? Yes Nog) Homeless or at risk of homelessness, e.g. residing in a shelter? Yes Noh) Residing in a Residential Facility (Class Two)? Yes Noe) Currently receiving treatment in an acute care setting, e.g., hospital orcrisis stabilization unit?i) Residing in another setting? (Please describe.)2) Where is the applicant currently residing or receiving treatment?Name of Residence/AddressTreatment SettingContact NamePhone/Email3) Does the applicant have a Legal Guardian?If Yes, please list below:Name/OrganizationYesNoAddress4) Will the applicant have a Representative Payee for RSS benefits?Phone/Fax/EmailYesIf Yes, please list below (do not indicate the nursing facility or facility operator):Name/OrganizationAddressDMHAS-7046 (Rev. 01/18)*Ensure this is the latest version of the form at www.mha.ohio.gov/RSSNoPhone/Fax/EmailPage 1 of 2
Residential State Supplement(RSS) Program Application5) Which RSS-Eligible Living Arrangement has been selected by the applicant or where the applicant is currently living?(Please refer to the updated listing of eligible living arrangements at www.mha.ohio.gov/RSS.)Living Arrangement/AddressFacility NameCountyScheduled Move Date(if applicable)Contact NamePhone/Email6) Does the applicant have a diagnosis of the following?If YES, please list below:a) Mental IllnessYesNoYesNob) Alcohol and Other Drug(AOD) Disorderc) Developmental/IntellectualDisabilityd) Physical Disability7) Does the applicant need Community-Based Services?If YES, please indicate from which local providers the applicant currently receives or has applied for services:Agency NameCase Manager NamePhoneEmailAgingAODMental HealthDevelopmental/Intellectual DisabilityOtherPlease send the following documents via fax to (614) 485-9747 or encrypted e-mail to [email protected] to complete the RSSapplication process:Confidential Fax Cover SheetRSS Program ApplicationRSS Authorization for Release of InformationODJFS 07120 FormProof of Legal Guardianship (if applicable)* Only completed applications submitted correctly will be reviewed. All forms & instructions are available online atwww.mha.ohio.gov/RSSDMHAS-7046 (Rev. 01/18)*Ensure this is the latest version of the form at www.mha.ohio.gov/RSSPage 2 of 2
Residential State Supplement Authorizationfor Release of InformationI, [ ], hereby authorize the Ohio Department of(Individual’s First & Last Name)(Date of Birth)Mental Health and Addiction Services (OhioMHAS) to release my Protected Health Information (PHI) and other personal,non-public information to the individuals or agencies listed below for the purpose of facilitating my enrollment in theResidential State Supplement (RSS) Program, confirming my residence is an eligible living arrangement, assisting with mypossible transition from an institution to an integrated community setting, and helping obtain local resources and services.I understand that PHI and other personal, non-public information includes, but may not be limited to, my social securitynumber, date of birth, address, phone number, income type and/or amount, physical or behavioral health diagnoses, andprevious or current treatment and services received. Ohio Department of Job and Family Services (ODJFS) and County Department of Job and Family ServicesOhio Department of Medicaid (ODM)Ohio Department of Aging (ODA) and Area Agencies on AgingOhio Department of Developmental Disabilities (DODD) and County Boards of Developmental DisabilitiesAlcohol, Drug Addiction, and Mental Health (ADAMH) or Alcohol and Drug Addiction Services (ADAS) BoardsProviders contracting with OhioMHAS, ODM, ODA, DODD or ADAMH/ADAS BoardsResidential Facility Operator or Residential Care Facility Operator; please enter name of facility and operatorhere: Representative Payee (if applicable); please enter name of individual or agency acting as payee for RSS benefitshere: Nursing Facility (if applicable); please enter name of facility here:My refusal to sign this authorization will NOT exclude me from enrolling in the RSS program, but may impact theOhioMHAS’ ability to act on my behalf in obtaining benefits and assisting with my transition to an integrated communitysetting. This authorization will remain effective for 365 days unless an earlier date or condition/event is specified here:. I understand I have the right to revoke this authorization in writing, at any time, and that therevocation will be effective except to the extent that OhioMHAS has already taken action in reliance on my authorization.My written statement that I want to revoke my authorization should be delivered to: Community Transitions c/oOhioMHAS, 30 E. Broad Street, 36th Floor, Columbus, OH, 43215.Printed Name of Individual or Legal Guardian (if applicable)Signature of Individual or Legal Guardian (if applicable)Date Signed (mm/dd/yyyy)If this authorization has been signed by a legal guardian on behalf of an individual, his/her authority to act on behalf ofthe individual must be set forth here: .NOTE: This information has been disclosed to you from records whose confidentiality is protected from disclosure by state and federal law. ORC 5119.27, 5119.28, 5122.31, and/or 42 CFR Part 2 prohibit you from makingany further disclosure of it without the specific and informed release of the individual to whom it pertains, their authorized representative, or as otherwise permitted by law. A general authorization for release of informationis NOT sufficient for this purpose.Please return to Community Transitions via encrypted email to [email protected] or fax to 614-485-9747.Updated 1/2018
Name of Provider or Individual Assisting withCompletion:Date (mm/dd/yyyy):Phone and Email:Recovery Requires a Community Authorization for Release of InformationI, [ ], hereby authorize the Ohio Department(Individual’s First & Last Name)(Date of Birth)of Mental Health and Addiction Services to release my Protected Health Information (PHI) and other personal, non-publicinformation to the individuals or agencies listed below for the purpose of facilitating my enrollment in the RecoveryRequires a Community Program and to assist with my transition from an institution to an integrated community setting. Iunderstand that PHI and other personal, non-public information includes, but may not be limited to, my social securitynumber, date of birth, address, phone number, income type and/or amount, physical or behavioral health diagnoses, andprevious or current treatment and services received. Ohio Department of Medicaid (ODM)Alcohol, Drug Addiction, and Mental Health (ADAMH) or Alcohol and Drug Addiction Services (ADAS) BoardsProviders contracting with OhioMHAS, ODM, ODA or ADAMH/ADAS BoardsOhio Department of Aging (ODA) and Area Agencies on AgingI authorize the following information to be released to providers or agencies involved in my transition and stabilization inthe community, as well as for the purpose of the evaluation of the program: Medicaid information, including claims dataHelping Ohioans Move Expanding (HOME) Choice documentationDocumentation required for Recovery Requires a Community application and enrollmentDiagnoses or treatment for mental health or substance use disordersDiagnoses or treatment relating to other communicable diseasesPre-Admission Screening and Resident Review (PASRR) information related to institutional stayMy refusal to sign this authorization will NOT affect my ability to obtain treatment, payment, or enrollment in a healthplan. This authorization will remain effective for 365 days unless an earlier date or condition/event is specified here:. I understand I have the right to revoke this authorization in writing, at any time, and that therevocation will be effective except to the extent that OhioMHAS has already taken action in reliance on my authorization.My written statement that I want to revoke my authorization should be delivered to: Community Transitions c/o OhioMHAS,30 E. Broad Street, 36th Floor, Columbus, OH, 43215.Printed Name of Individual and Legal Guardian (if applicable)Signature of Individual or Legal GuardianDate Signed(mm/dd/yyyy)If this authorization has been signed by a legal guardian on behalf of an individual, his/her authority to act on behalf ofthe individual must be set forth here: .NOTE: This information has been disclosed to you from records whose confidentiality is protected from disclosure by state and federal law. ORC 5119.27, 5119.28, 5122.31, and/or 42 CFR Part 2 prohibityou from making any further disclosure of it without the specific and informed release of the individual to whom it pertains, their authorized representative, or as otherwise permitted by law. A generalauthorization for release of information is NOT sufficient for this purpose.Please return to Community Transitions via encrypted email [email protected] or fax 614-488-4504prior to discharge from the nursing facility.Updated 4/2016
RECOVERY REQUIRES A COMMUNITYPROGRAM APPLICATIONPlease keep in mind that you only need to fill out sections for which you are requesting funding. However, you are required toalways send the Basic Information section, as well as the Final Calculation and Attestation.Required Supplemental Information: Release of Information, signed by the individual or legal guardian (when applicable). A signed ROI must be on file priorto transition from the institution (such as a nursing home or residential treatment facility).Documentation of Behavioral Health Diagnosis (mental health or substance use disorder)Quotes or Cost Estimates (when applicable – minimum three bids required for home modifications)For assistance with completing this application, please contact Recovery Requires a Community by phone at 614-644-0617, orencrypted email [email protected] submit this application and all supporting documents via encrypted email to [email protected] or fax to 614-488-4504 prior tothe individual’s discharge from the nursing facility.Demographic InformationIndividual’s Name:Medicaid ID #:Date of Birth:Social Security #:Gender: Male Female OtherName, Address, County of Current Facility:Legal Guardian Name, Phone, Address (whenapplicable)Anticipated Transition Date (MM/DD/YYYY):Estimated Monthly Income Upon Transition:Contact Information Upon Transition:Pre-Transition Case Manager (Name and Phone):Transition Coordinator (Name, Phone, Agency):Diagnostic Information:Axis I:Axis II:Application Index – Page 1, Page 2 Resource Checklist, and Page 5 must be completed for all categories of assistance.For Housing AssistanceFor Utility AssistanceFor SILAFor Other Non-Categorized Needs1 P a g eUpdated 1/2017Page 2Page 3 (top half)Pages 3-4Page 4 (bottom half)
Individual Resource ChecklistPlease indicate which of these linkages have been facilitated as part of the transition.Residential State Supplement (RSS) Date (MM/DD/YYYY):Tenant-Based Housing VoucherHome Energy Assistance Program (HEAP)and/or Percentage of Income Payment Plan(PIPP)Community Behavioral Health AgencyOhio Dept. of Job and Family Services(ODJFS) (Income Verification & FoodAssistance)HOME Choice (Ohio Department ofMedicaid)Home Health Services Date (MM/DD/YYYY): Date (MM/DD/YYYY): Date (MM/DD/YYYY): Date (MM/DD/YYYY):Date (MM/DD/YYYY):Date (MM/DD/YYYY):Housing Assistance1.Please rank the following housing types from one to four(1-4) where one (1) means it is most preferred housing &four (4) means it is least preferred.Each number may be used only once.Housing ChoicesA. Live in a house, apartment, or room by yourselfRank2.What is the amount of rent for the unit?3. Has someone visited the housing and deemed it safe andaccessible for the individual?B. Live in a house, apartment, or room with familyC. Live in a house, apartment, or room withroommate(s)4. If housing has been selected, what is the address of theunit?D. Live in a group setting (Adult Care Facility)Budget & CalculationLine Number1Budget and CalculationIndividual’s current monthly gross income (rounded to nearest dollar)2Required amount individual will pay toward rent: Please multiplyamount in line 1 by 0.30 (30%).If known, please enter the amount of rent here. If unknown, mark“n/a” and use only the Fair Market Rent calculation.Fair Market Rent: Please refer to this document for current Fair MarketRents. If this number is smaller than #3, please enter it here.Amount per month of Recovery resources needed: Please subtract theamount from line 2 from the smaller amount from Line 3 or 4.Multiply the amount in Line 5 by the number of months needed (Pleaseput total here):Arrears owed to Housing Authority, landlord, or complex (Please puttotal here):Please enter the total of Line 6 and/or 7 here and on the final page of theapplication:3456OR 7TOTAL2 P a g eUpdated 1/2017Amount
Utility AssistanceNote: Recovery Requires a Community may be able to assist with one-time payment of utility arrears or temporary assistancewith utility payments.Utility Assistance Checklist ArrearsType:or Temporary Assistance Gas Water ElectricCompany:Please indicate which resources have been utilized related if a debt is described: Legal Aid (for non-utility debts) Credit CounselingBalance Negotiation with Involved CompanyBudget & Calculation1. What is the current remaining debt or need presenting as a challenge to the individual’s transition?SourceTOTAL:Amount (rounded to nearest dollar)Please enter this amount on the final page:Supplemental Independent Living AssistanceNote: SILA services assist in the development of skills needed for sustainable community living. Recovery Requires aCommunity may assist in paying for these supplemental services when they are clearly shown to benefit applicants and help them stayin the community as long as other resources (such as HOME Choice) have already been pursued. Additionally, this may coverservices that an individual would receive via Home and Community Based Waiver, but may have a gap in service provision.ChecklistWhich services are you requesting for the individual? Independent Living Skills Training Nutritional Consultation1. Community Support Coaching Waiver Services (ex: home health) Social Work/Counseling Other:Please explain how this service will support the individual and contribute towards sustainability in the community.3 P a g eUpdated 1/2017
2.Has the individual applied for waiver services? Yes NoIf so, is there an expected gap in service provision? Yes3. NoPlease select what other options have been pursued to provide a similar service: Peer Support Faith-based Community Senior Center Other:Budget and CalculationService Independent Living Skills TrainingRate 30.00/hr. Community Support Coaching 25.00/hr. Social Work/Counseling 64.12 Nutritional Consultation 52.56 Peer Support Services 62.04TOTALHours RequestedTotal Requested(example 10hrs x 30.00)( 300.00)Please enter this amount on the final page:OtherNote: Because of its broad scope, the “Other” category requires more coordination between Recovery Requires a Communitystaff and a transition planning team in order to make sure that all possible resources have been exhausted in the localcommunity. Please consider and address below whether all other resources of possible benefit have been pursued toprovide this need.ChecklistGoods & ServicesTransportationHome Modifications (Three bids attached)Other (Please specify below)1. Based on the indications above, please provide additional detail regarding the nature of the request. What has beendone up to this point in order to try to provide resources for that need?Budget & Calculation1. Please fill out this table, indicating the amount of hours requested (if applicable), and the total amount of moneyindicated.ServiceTotal RequestedTOTAL:4 P a g eUpdated 1/2017Please enter this amount on the finalpage:
Please provide additional information that may help with reviewing this individual’s application:Final Calculation & AttestationTotal Request to Recovery Requires a CommunityTake the totals from each category and list them below:CategoryMoney Requested ( )Housing Utility Assistance Supplemental Independent Living Assistance Other TOTAL:By voluntarily signing this form, I hereby declare, certify and affirm that the information I have provided on this application,including all attachments and supporting documentation, is true and accurate to the best of my knowledge and belief.Applicant NameApplicant SignatureDate (MM/DD/YYYY)By voluntarily signing this form, I hereby declare, certify and affirm that the information I have provided on this application,including all attachments and supporting documentation, is true and accurate to the best of my knowledge and belief.Providing any misleading information, or engaging in fraudulent activities will result in my agency providing repayment ofRecovery Requires a Community funds to the Ohio Department of Mental Health and Addiction Services, and will also forfeitmy agency’s ability to receive additional Recovery Requires a Community funds in the future.Provider Agency Name5 P a g eUpdated 1/2017Staff Member RepresentativeDate (MM/DD/YYYY)
Ohio Department of MedicaidHOME CHOICE APPLICATIONApplicant Name (Last)FirstMIIs the applicant on Medicaid?YesNoCountyMedicaid ID Number (12 digits)Applicant Phone NumberGenderDate of Birth (mm/dd/yyyy)MFDate of Facility Admission (mm/dd/yyyy)Name of FacilityInstitutional Stays Prior to this facility stay (mm/dd/yyyy)Street AddressFacility Phone NumberCityStateType of FacilityZip CodeFacility FAX NumberHospitalNursing FacilityQualified Residential Treatment Center (individual under the age of 22 only)ICF-IIDPsychiatric Hospital (individual under the of age 22 and over the age of 60 only)Facility Social Worker/Point of Contact (Name)Phone NumberEmail (Preferred) or FaxNumberReferral SourceSelfCILNursing FacilityFamily and Children First CouncilFriendCLSICF-IIDPhysicianCounty Board of DDFamilyLTC OmbudsmanPASRROther (specify)HospitalCommunity Agency (specify)Person referring Phone NumberName of person making referralDoes the applicant have income?YesReferral Date (mm/dd/yyyy)If yes to anydiagnoses, is theapplicant receivingtreatment orservices?No (specify)Does the applicant have a mental health diagnosis?YesDoes the applicant have a drug and/or alcohol diagnosis?No (specify)YesNo (specify)Does the applicant have a developmental disability diagnosis?YesNo (specify)YesNoAdditional information that will assist in processing this applicationWho else might we contact about the person being referred?Contact Phone NumberThe following must be filled out if applicant has a legal guardian or is under the age of 18.LEGAL GUARDIAN (if applicable)Name (Last)FirstMIAddressCityStateType of GuardianshipPersonEstateZip CodePerson and EstatePhone NumberPARENT (if applicant is under the age of 18)Name (Last)AddressFirstCityStateMIZip CodeSignature of Applicant or Legal Guardian (REQUIRED)Submit completed form to:Ohio Department of Medicaid/Office of OperationsHOME Choice OperationsP O Box 182709, 4th FloorColumbus, Ohio 43218-2709Email: HOME [email protected]: (888) 221-1560ODM 02361 (Rev 7/2017)Phone NumberDate (mm/dd/yyyy)FAX: (614) 360-3549
RSS Authorization for Release of Information ODJFS 07120 Form Proof of Legal Guardianship (if applicable) . non-public information to the individuals or agencies listed below for the purpose of facilitating my enrollment in the Residential State Supplement (RSS) Program, confirming my residence is an eligible living arrangement, assisting .