Downloading a Form to Your Computer
Fillable forms cannot be viewed on mobile or tablet devices. Follow the steps below to download and view the form on a desktop PC or Mac.
- Right Click for PC or Ctrl + Click for Mac on the PDF link and click “Save link as” from the menu.
- Select the folder you want to save the file in and then click "Save."
- Navigate to the folder you saved the file in and Right Click for PC or Ctrl + Click for Mac, then select "Open With" from the menu and select Adobe Acrobat Reader DC.
Note: Open the PDF file from your desktop or Adobe Acrobat Reader DC. Do not click on the downloaded file at the bottom of the browser since it will not open the PDF in Adobe Acrobat Reader DC. It will try to open the file in the browser that results in the same browser error message.
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This form serves as documentation that an individual who refuses to pay the required contribution to the cost of care in a Residential Care (RC), Adult Foster Care (AFC) or Assisted Living (AL) facility has been advised of the eligibility requirements and consequences of failure to meet those requirements.
When to Prepare
Complete this form when an individual refuses to make the required room and board payments or copayments in an RC, AFC or AL facility. The form must be reviewed with the individual and any responsible party and signed by the individual or responsible party in acknowledgement that the information has been shared.
Number of Copies
The case worker/service coordinator retains the original copy with the individual's signature in the case record. A second copy is given to the individual and a third copy may be given to the individual's responsible party.
Review the form with the individual, his responsible party, or both. Request that the individual sign and date the form or, if the individual is unable to sign, request that the responsible party sign and date the form.
The case worker/service coordinator signs and dates the form.
If the individual refuses to sign the form, have a witness enter his name acknowledging that he was present when the eligibility requirements and consequences were explained to the individual.
Enter the individual's name.
The witness signs and dates the form.