Blank Rem Iowa Service Application PDF Form

The REM Iowa Service Application Form is a crucial document for individuals seeking services related to intellectual disabilities, developmental disabilities, and mental health. This form collects essential information about the applicant, including their personal details, desired services, and any relevant medical history. To ensure a smooth application process, please complete the form by clicking the button below.

The REM Iowa Service Application form is an essential document for individuals seeking community services related to intellectual disabilities, developmental disabilities, or mental health needs. This comprehensive application gathers vital information about the applicant, including personal details such as name, address, and contact information, as well as specific needs related to their diagnosis. It also addresses legal guardianship status, financial responsibilities, and the desired types of services, which may include various community living arrangements and support options. Additionally, the form requires a history of past services and any relevant medical or behavioral information, ensuring that the service providers have a complete understanding of the applicant's needs. By collecting this information, REM Iowa aims to facilitate the best possible match between applicants and the services they require, promoting a supportive and effective care environment.

Outline

Document Sample

REM IOWA COMMUNITY SERVICES & REM IOWA DEVELOPMENTAL SERVICES

SERVICE APPLICATION FORM FOR ID/DD/MH SERVICES

Date of Application:

REFERRAL TO REM IOWA

How did you become aware of REM Iowa services?

Family | Friend

REM Iowa website

The MENTOR Network website

Hospital

REM Employee

Other Provider

Case Manager | Care Coordinator

Other

If other, please document from whom/where:

APPLICANT INFORMATION

Applicant’s Full Name:

When Desired:

Placement in Jeopardy

Next Available

Within six months

Within one year

If placement in jeopardy, indicate the date of discharge:

Current Address:

Telephone Number:

Birth Date:

Gender:

Male

Female

Height:

Weight:

lbs.

Primary Diagnosis:

Intellectual Disability

Mental Health/Illness

Autism Spectrum:

Yes

Personality Disorder:

Yes

Schizophrenia or Schizoaffective Disorder:

Yes

Other Diagnosis:

LEGAL GUARDIANSHIP STATUS

Does this applicant have a guardian?

Yes

Name of Guardian:

Relationship:

FINANCIAL RESPONSIBILITY

Case Manager | Care Coordinator Name:

Telephone Number:

Email:

IME Determination Date:

Level of

Care:

SERVICE(S) DESIRED

Type of Services Desired:

ICF/ID

24-hour Waiver (Adult)

24-hour Habilitation

Host Home**

Communities desired:

Day Habilitation (*indicates available communities below)

Unknown

1. Children ICF/DD (ID must be primary diagnosis):

Council Bluffs Only

Adult ICF/DD (ID must be primary diagnosis):

1st Opening

Shelby

Washington

Coralville

Cedar Rapids | Marion | Hiawatha

No preference

Waiver Services:

1st Opening

Des Moines Area*

Mt. Pleasant

Atlantic

Ft. Madison

Mt. Vernon

Avoca

Harlan

Shelby

Cedar Rapids |Marion| Hiawatha*

Iowa City|Coralville*

Tipton

Clinton

Keokuk

Vinton*

Council Bluffs

Marshalltown*

Waterloo | Cedar Falls |Waverly

Davenport | Bettendorf

Mason City

No Preference

Other community (s):

**Host Home is a service where individuals live in private family homes and receive specialized assistance from a dedicated caregiver we call a Mentor.

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HISTORY OF SERVICES

Residential/ in-home services (e.g. hourly services, 24-hour waiver, ICF/ID, nursing home, etc.)

Has the applicant always lived at home?	Yes	No

Service	Provider

Dates

Day/Vocational Services
Has the applicant ever been employed:	Yes	No	At a day program?	Yes	No

Service

Provider

Dates

REFERRAL HISTORY

Has the applicant ever been arrested?

Yes

If yes, provide: Date(s):

Reason(s):

Outcomes:

Does the applicant have a current court committal?	Yes	No
Has the applicant been accused/convicted of sexual abuse?			Yes	No
If yes, provide: Date(s):
Outcomes:
Has the applicant had any history of cruelty to animals?			Yes	No
If yes, provide: Date(s):
Outcomes:
Has the applicant attempted suicide or had suicidal ideations?			Yes	No
If yes, provide: Date(s):
Outcomes:
Has the applicant had any history of fire setting?			Yes	No
If yes, provide: Date(s):
Outcomes:
Has the applicant had any history of cutting self, swallowing or insertion of foreign objects or			Yes	No
strangulation?
If yes, provide: Date(s):
Outcomes:
Has the applicant had physical aggression that required physical, mechanical or chemical restraint
via injection over the past 12 months?			Yes	No

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FAMILY INFORMATION

Mother’s Name (first & last):

Address:

Home Telephone #:

Work Telephone #:

Email Address:

Father’s Name (first & last):

Address:

Home Telephone #:

Work Telephone #:

Email Address:

Sibling’s Full Name(s) (first & last):

Significant Other Name (first & last):

Address:

Home Telephone #:

Work Telephone #:

Email Address:

APPLICANT’S FINANCIAL INFORMATION

Receive Financial Assistance:

Yes

If yes, type:

SS (Social Security)

SSI (Supplemental Social Insurance)

If other, document type:

VA (Veteran’s Benefits)

Child Support

Adoption Subsidy

Other

Does applicant have Title 19?

Yes

Managed Care Organization (MCO)?

Amerihealth Caritas

Amerigroup

United Health

Optum N/A

Does applicant have Waiver funding?

Yes

Does applicant have Habilitation funding?

Yes

Does applicant have private insurance?

Yes

Does applicant have other income (trust fund, etc.)?

Yes

APPLICANT’S HEALTH/MEDICAL INFORMATION

Current Medication(s) or can attach current medication orders or record:

Name	Dose	Frequency	Reason for Taking

Prescribed By

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Revised 03.17

Physical disabilities that require the use of adaptations (e.g. AFOs {braces}, orthopedic shoes, cane, walker, wheelchair,

etc.)	Yes	No
If yes, list adaptive equipment:
Seizures:	Yes	No	History of
If yes or history of, describe type and frequency:
Vision Problems:		No	Yes – correctable with glasses		Yes – but chooses not to wear glasses
		Yes - uncorrected		Blind Comments:
Hearing Problems:		No	Yes – correctable with hearing aides		Yes – but chooses not to wear hearing aides
		Adapt by others speaking louder			Deaf

Comments:

Skill Checklist: (please check items which best describe applicant)

BEHAVIOR	Consistently Sometimes Never Comments
Becomes upset when
redirected/corrected
Demands excessive
attention from others
Complains of being
persecuted
Pretends to be ill
Changes mood without reason
Bosses or manipulates others
Hyperactive
Hoards things
PICA (eats inedible objects) (if
displays, list items in
comments)
Self stimulation
Self injurious behavior
Verbally aggressive
Physically aggressive toward
others
Physcially aggressive toward
objects
Displays sexually inapprorpriate
behavior
Removes clothing in public
Tears clothing
Steals other's belongings
Elopes / runs away from home
Uses tobacco
Uses alcohol
Uses other drugs

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LEISURE ACTIVITIES

Interests:

Hobbies:

Dislikes:

CLOSING

The information we have asked you to provide is necessary for the effective administration of the services for which you are applying. The information collected will only be used by authorized agency personnel. Use of this information for purposes other than expressed herein will not occur without your prior written approval, unless such other use is specifically authorized by law.

Attach any of the following materials that may be helpful in determining eligibility for service:

Most recent psychological evaluation

Most recent education and/or vocational report

Most recent progress reports or plan of care

Physical and/or specialty medical examinations

Other Documentation that you feel would be helpful


Completed by:
Applicant Name:					Date:
Case Manager Name:					Date:
Parent/Guardian Name:					Date:
Name/Title:					Date:

Please return form to: REM Iowa (please check website for current contact information @ www.remiowa.com)

or send to [email protected]

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Revised 03.17

Get Rem Iowa Service Application

File Specifics

Fact Name	Description
Application Purpose	The REM Iowa Service Application form is designed for individuals seeking ID/DD/MH services.
Governing Law	This form complies with Iowa Code Chapter 225C, which governs services for individuals with disabilities.
Required Information	Applicants must provide personal details, including diagnosis, financial information, and history of services.
Submission Guidelines	Completed forms should be returned to REM Iowa via their website or the specified email address.

How to Use Rem Iowa Service Application

After completing the REM Iowa Service Application form, submit it to the appropriate contact at REM Iowa. The information provided will be used to assess eligibility for services. Ensure all sections are filled out accurately to facilitate the review process.

Date of Application: Enter the date you are filling out the form.
Referral to REM Iowa: Indicate how you learned about REM Iowa services by checking the appropriate box.
Applicant Information: Fill in the applicant's full name, desired placement timeframe, current address, telephone number, birth date, gender, height, weight, and primary diagnosis.
Legal Guardianship Status: Specify if the applicant has a guardian. If yes, provide the guardian's name and relationship.
Financial Responsibility: Provide the case manager or care coordinator's name, telephone number, and email address. Include the IME determination date and level of care.
Services Desired: Check the type of services desired and indicate any specific communities for services.
History of Services: Answer whether the applicant has always lived at home and provide details of any previous service providers and employment history.
Referral History: Answer questions regarding any arrests, court commitments, or other relevant histories.
Family Information: Fill in the names, addresses, and contact information for the applicant's parents and significant others.
Applicant’s Financial Information: Indicate if the applicant receives financial assistance and provide details about insurance or funding.
Applicant’s Health/Medical Information: List current medications, any physical disabilities, and provide information on seizure history, vision, and hearing problems.
Skill Checklist: Check the boxes that describe the applicant's behavior and provide comments as necessary.
Leisure Activities: Fill in the applicant's interests, hobbies, and dislikes.
Closing: Ensure all required signatures are obtained, including those of the applicant, case manager, and parent/guardian, along with the respective dates.
Submission: Return the completed form to REM Iowa, checking the website for current contact information or sending it via email.

Your Questions, Answered

What is the purpose of the REM Iowa Service Application form?

The REM Iowa Service Application form is designed to collect essential information about individuals seeking services related to intellectual disabilities, developmental disabilities, and mental health. This information helps REM Iowa assess eligibility and determine appropriate services for applicants.

How do I fill out the application form?

To complete the application, provide accurate information in each section. Start with your personal details, including your full name, current address, and contact information. Next, indicate your desired services and any relevant medical or financial information. Make sure to answer all questions as thoroughly as possible to avoid delays in processing.

What types of services can I request on this application?

Applicants can request various services, including:

ICF/ID (Intermediate Care Facility for Individuals with Intellectual Disabilities)
24-hour Waiver services
24-hour Habilitation
Host Home services
Day Habilitation

Specify your preferences for communities or types of services as needed.

What should I do if I have a guardian?

If the applicant has a guardian, include their name and relationship to the applicant in the designated section of the form. This information is crucial for communication and decision-making regarding services.

How will my information be used?

The information provided in the application will only be used by authorized personnel for service administration. It will not be shared for any other purposes without your written consent, unless required by law.

What if I have additional documents to submit?

You may attach relevant documents to support your application. Helpful materials include:

Most recent psychological evaluation
Education or vocational reports
Progress reports or plans of care
Medical examination records

These documents can help in determining eligibility for services.

Is there a deadline for submitting the application?

While there is no specific deadline, it is advisable to submit your application as soon as possible. This ensures timely processing and helps secure the desired services for the applicant.

Who should I contact if I have questions about the application?

If you have questions or need assistance while completing the application, you can reach out to REM Iowa directly. Contact information is available on their website, or you can email them at [email protected].

How will I know if my application has been received?

You should receive a confirmation once your application has been processed. If you do not hear back within a reasonable timeframe, consider following up with REM Iowa to ensure your application is on file.

Common mistakes

Failing to provide accurate applicant information. Ensure that the full name, birth date, and current address are filled out correctly. Any discrepancies can delay processing.
Not specifying the desired services clearly. Be specific about the type of services needed, whether it's ICF/ID, 24-hour Waiver, or others. Ambiguity can lead to misunderstandings.
Overlooking financial information. Complete the financial section thoroughly. Missing information about financial assistance or insurance can affect eligibility.
Neglecting to indicate legal guardianship status. If the applicant has a guardian, this must be documented. This information is crucial for legal and administrative purposes.
Skipping the history of services section. This section provides essential context about the applicant's previous experiences and needs. Omitting it may hinder the assessment process.
Inadequate detail in the referral history. If there are any legal issues or past incidents, provide thorough explanations. This helps in understanding the applicant's background.
Not checking for medical information completeness. Include all current medications and medical conditions. This information is vital for ensuring appropriate care.
Failing to attach necessary supporting documents. Include any evaluations or reports that can aid in determining eligibility. Missing documents can lead to delays or denials.

Documents used along the form

The Rem Iowa Service Application form is a crucial document for individuals seeking services related to intellectual disabilities, developmental disabilities, or mental health issues. Along with this form, several other documents may be required to ensure a comprehensive understanding of the applicant's needs and circumstances. Below is a list of additional forms and documents that are often used in conjunction with the Rem Iowa Service Application.

Psychological Evaluation: This document provides insights into the applicant's mental health status and cognitive functioning. It is typically prepared by a licensed psychologist and is essential for determining eligibility for services.
Education Report: This report outlines the applicant's educational history, including any special education services received. It helps assess the individual's learning needs and capabilities.
Vocational Report: Similar to the education report, this document focuses on the applicant's work history and skills. It is particularly useful for those seeking employment-related services.
Progress Reports: These reports summarize the applicant's progress in previous services or programs. They help identify areas of improvement and ongoing needs.
Medical Examination Records: Documentation of any physical health assessments or specialty evaluations is vital. This information aids in understanding the applicant's overall health and any medical accommodations needed.
Financial Assistance Documentation: Proof of any financial assistance the applicant receives, such as Social Security or VA benefits, is necessary for determining eligibility for services.
Guardian Documentation: If applicable, legal documents confirming the appointment of a guardian must be provided. This ensures that the rights and responsibilities of the guardian are recognized in the application process.

Collecting these documents along with the Rem Iowa Service Application can streamline the process and provide a clearer picture of the applicant's needs. It is advisable to ensure that all information is accurate and up-to-date to facilitate timely service delivery.

Similar forms

The Rem Iowa Service Application form shares similarities with the Medicaid Application form. Both documents require detailed personal information, including the applicant's full name, date of birth, and address. They also seek information about the applicant's financial situation, such as income sources and assistance received. This information is crucial for determining eligibility for services. Additionally, both forms ask for information regarding the applicant's medical and health history, ensuring that the services provided align with the individual's needs.

Another document that resembles the Rem Iowa Service Application is the Individualized Education Program (IEP) form. Like the service application, the IEP form gathers extensive information about the individual, including their strengths, weaknesses, and specific needs. Both documents emphasize the importance of a tailored approach to service delivery. The IEP focuses on educational goals, while the service application centers on health and community services. However, both aim to create a support system that addresses the unique requirements of the individual.

The Social Security Disability Insurance (SSDI) application is also similar to the Rem Iowa Service Application. Both forms require applicants to provide personal identification details, medical history, and information about their disabilities. The SSDI application assesses an individual's eligibility for financial support, while the Rem Iowa application seeks to determine eligibility for community services. Both documents play a crucial role in connecting individuals with the assistance they need to improve their quality of life.

In addition, the Supplemental Nutrition Assistance Program (SNAP) application shares common elements with the Rem Iowa Service Application. Each form collects personal and financial information to assess eligibility for assistance. Both applications require details about household composition and income sources. While the SNAP application focuses on food assistance, the Rem Iowa application is geared towards health and community services. Both serve to support individuals and families in need, ensuring they have access to essential resources.

The Housing Assistance application is another document that parallels the Rem Iowa Service Application. Both require detailed information about the applicant's current living situation, including household members and financial status. The Housing Assistance application aims to determine eligibility for subsidized housing, while the Rem Iowa application assesses eligibility for health and developmental services. Each form plays a vital role in helping individuals secure the support they need to thrive in their communities.

Additionally, the Veterans Affairs (VA) benefits application shares similarities with the Rem Iowa Service Application. Both forms require information about the applicant's personal history, including medical conditions and financial status. The VA application focuses on determining eligibility for benefits and services available to veterans, while the Rem Iowa application seeks to connect individuals with community and developmental services. Both processes ensure that applicants receive the necessary support tailored to their unique circumstances.

The Child and Family Services application is another comparable document. This application gathers information about the family structure, financial status, and the needs of the children involved. Like the Rem Iowa Service Application, it aims to assess eligibility for support services. Both documents emphasize the importance of understanding the individual and familial context to provide appropriate assistance. The focus may differ, but the underlying goal remains the same: to support those in need effectively.

Lastly, the Application for Long-Term Care services is similar to the Rem Iowa Service Application. Both forms require comprehensive details about the applicant's health, medical history, and financial information. The long-term care application focuses on assessing eligibility for extended care services, while the Rem Iowa application is designed to connect individuals with community-based services. Both documents are essential in ensuring that individuals receive the appropriate care and support they require for their unique situations.

Dos and Don'ts

When filling out the Rem Iowa Service Application form, it is essential to follow certain guidelines to ensure that the process goes smoothly. Here’s a helpful list of things you should and shouldn’t do:

Do read the entire application form carefully before starting. Understanding all sections will help you provide accurate information.
Do gather all necessary documents, such as medical records and financial information, before you begin filling out the form.
Do provide clear and concise answers. Use straightforward language to describe the applicant’s needs and history.
Do double-check all information for accuracy. Mistakes can delay the application process.
Don't leave any required fields blank. If a section does not apply, indicate that with "N/A" to avoid confusion.
Don't rush through the application. Take your time to ensure that each section is completed thoroughly.
Don't hesitate to ask for help if you’re unsure about any part of the form. Contacting a case manager or a representative can provide clarity.

Misconceptions

Understanding the REM Iowa Service Application form is crucial for applicants and their families. However, several misconceptions can lead to confusion. Here are nine common misunderstandings:

The application is only for individuals with intellectual disabilities. Many people believe that the form is limited to intellectual disabilities. In reality, it also accommodates individuals with mental health issues and other diagnoses.
All information provided is public. Some applicants worry that their personal details will be shared. The information is confidential and used solely for service administration.
Submitting the application guarantees immediate service. While the application is a necessary step, it does not guarantee immediate placement. Availability depends on various factors, including service demand.
Only certain types of funding are accepted. There is a belief that only specific financial assistance types are valid. The application recognizes various funding sources, including private insurance and VA benefits.
All applicants need a legal guardian. Many think that a guardian is mandatory for application. However, individuals can apply independently if they meet the criteria.
Past legal issues disqualify applicants. Some assume that any history of legal trouble will prevent them from receiving services. Each case is evaluated individually, and past issues do not automatically disqualify an applicant.
The form is too complex for families to fill out. While the form may seem detailed, it is designed to gather essential information. Assistance is available from case managers if needed.
There are no options for community preferences. Some applicants believe they must accept any available placement. In fact, the form allows individuals to specify their preferred communities.
Health information is not relevant to the application. Many think that medical history is not necessary. However, health information is crucial for determining the appropriate level of care and services needed.

Addressing these misconceptions can help applicants and their families navigate the application process more effectively. Understanding the true nature of the REM Iowa Service Application form ensures that individuals receive the support they need.

Key takeaways

Filling out and using the REM Iowa Service Application form requires careful attention to detail. Here are key takeaways to keep in mind:

Complete all sections: Ensure that every section of the application is filled out accurately. Missing information can delay the processing of your application.
Document any special circumstances: If the applicant has unique needs or situations, provide detailed explanations in the designated sections. This helps service providers understand the applicant better.
Attach supporting documents: Include any relevant documentation, such as psychological evaluations or medical reports. These materials can assist in determining eligibility for services.
Be honest about history: Disclose any relevant history, including legal issues or past services. Transparency is crucial for appropriate service planning.
Check contact information: Verify that all contact details are correct. This ensures that communication from REM Iowa reaches the right individuals without delay.