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Effective Date: 



Updated: 12/2014


Form 2060-B is used as a guide for collecting and documenting essential information not captured on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide.

This form is used by the case manager to:

  • collect information to determine needs for services other than personal assistance and Day Activity Health Services (DAHS)-XIX  services; and
  • serve as a worksheet for referrals for the following services:
    • Behavioral Health Services;
    • Supported Employment/Employment Assistance;
    • Transportation Assistance;
    • assistance with instrumental activities of daily living; and
    • assistance for other medical condition not previously addressed.


When to Prepare or Update

Form 2060-B is completed for Primary Home Care (PHC), Community Attendant Services (CAS) and Day Activity and Health Services Title XIX individuals as an addendum to Form 2060 at the initial contact, annual reassessment and any time a PHC, CAS or DAHS-XIX individual has a significant change request for a new service.

Detailed Instructions

I. General Information

1. Name of Applicant/Individual — Enter the name of the applicant/individual.

2. Medicaid ID No. — Enter the nine-digit Medicaid number of the applicant/individual.

3. Person Responding — Record the name of person responding.

4. Relationship (if other than applicant/individual) — Enter the relationship the person responding has with the applicant/individual.

5. Assessment Date — Enter the date this form is completed.

6.  Type of Contact — Check the Telephone or Home Visit box to indicate the method used to contact the applicant/individual.

7. Type of Service — Check the Primary Home Care, Community Attendant Services or Day Activity and Health Services XIX box to indicate the service the individual is receiving.

8. Reason for Contact — Check the appropriate box to indicate the reason the contact was made to the applicant/individual.

II. Assessment

The case manager will ask the applicant/individual or representative the questions in this section. Space is provided for additional explanation.

A. – List the diagnoses for which the applicant/individual currently receives treatment.

B. through G. – Ask the applicant/individual or representative the questions and record the responses. Ask additional questions to gain a thorough knowledge of the applicant’s/individual’s current medical and functional status.

H. through J. – Ask the applicant/individual or representative the questions and record the responses. Ask additional questions to gain a thorough knowledge of the applicant’s/individual’s functional status.

III. Additional comments and any referrals to be made:

Enter any additional comments regarding the applicant’s/individual’s medical and/or functional status. Include recommendations offered and discussed with the individual for referrals for services or supports identified, as well as any referrals made on behalf of the individual. Enter the individual’s refusal of a referral to an identified resource or service. Use this section if there is not adequate space under a specific question and note the section and letter of the question being continued.

Signature – Case Manager and Date – The case manager signs and dates the form.