Form Cf-Es 1006 - Alternate Care Certification Optional State Supplementation
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ALTERNATE CARE CERTIFICATION
OPTIONAL STATE SUPPLEMENTATION
Please print – Refer to instructions for assistance.
PART 1
CLIENT/FACILITY INFORMATION
Name (Last, First, M.I.)
Date Of Birth
Social Security Number
Date of Placement
OSS Status:
New
Change
Facility Name
Telephone Number
License Number
Expiration Date
Facility Address
Facility Type:
ALF
ALF–LMHL
AFCH
MHRTF
Home of Relative
Certification: The person named above is appropriate for this placement based on one of the following:
DOEA Form 1823, Health Assessment (ALF)
DOEA Form 1110, Health Assessment (AFCH)
Other Physician Certification (ALF or MHRTF); describe:____________________________________________
Type of Income:
Income Amount: $
$
$
SSI Status:
Application Pending
Recipient
SSI/SSDI Recipient Due to Psychiatric Disorder
Did Not Apply
SSI Denied (check if known at time of application)
AS, APD, MH or AAA / lead agency Signature
Print Name / Title / Agency and Telephone Number
Date
PART 2
AGREEMENT FOR ALTERNATE CARE
Client and provider agree to placement in above facility. Client agrees to pay provider following monthly rate:
Amount of $__________ equal to current recognized standard cost of care as set forth in Chapter 65A-2,
F.A.C., OSS. Client will keep personal allowance of $__________ per month.
Amount of $__________ per month, if less than standard cost of care.
Third Party Contribution: $__________ per month for third party payment in accordance with s.409.212, F.S.
Client Signature
Date
Provider Signature
Print Name / Title
Date
Witness Signature if signed with mark (not DCF, APD or DOEA) Print Name / Relationship to Client or Facility
Date
PART 3
(To be completed ONLY for Mental Health Resident residing in ALF–LMHL)
Client is appropriate to reside ALF–LMHL based on one of the following:
State mental hospital discharge evaluation documenting client’s appropriateness to reside in ALF–LMHL was
completed within 90 days prior to admission to the ALF–LMHL and is on file at the facility.
____________________________________
____________________________________
____________
A. Signature of Mental Health Professional
Title/Agency
Date
In my professional opinion, this person at this time and based on person’s Community Living Support Plan is
appropriate to reside in an ALF–LMHL. (Professional signature required below.)
________________________________
__________________________
____________
____________
B. Signature of Mental Health Professional*
Title/Agency
License Number
Date
________________________________
__________________________
____________
C. Supervisor Name*
Title/Agency
License Number
*Give supervisor information if professional signing in “B” is unlicensed.
If there is a Mental Health case manager, please specify in space below.
____________________________________
______________________________________________________
MH Case Manager’s Name**
Agency / Organization
**For mental health residents, the case manager must be the same person that signed in Part 1.
CF-ES 1006, PDF 10/2005
Distribution of Copies: Original and 1 Copy -- To Economic Self-Sufficiency (ESS)
Copy -- To facility for resident's record;
and
Copy -- To case manager for case management file
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