Appendix XIII, Content of Referral Packets

Revision 21-4; Effective December 1, 2021

Initial Referral Packet Forms

The initial packet must Include:

  • a cover sheet;
  • the Long-term Care Services Intake System (NTK) generated Form 2110, Community Care Intake; and
  • a copy of the following Service Authorization System Online Wizards (SASOW) generated forms.
Community Attendant Services (CAS)
Primary Home Care (PHC)
Day Activity and Health Services (DAHS)
DAHS Facility -Initiated Referrals		 Family Care (FC)
Residential Care (RC)		 Emergency Response Services (ERS)
Home Delivered Meals (HDM)		 Adult Foster Care (AFC)

Form 2059, Summary of Client's Need for Service;
Provider Referral Supplement;
Form 2060, Needs Assessment Questionnaire and Task/Hour Guide; and referral
Form 2101, Authorization for Community Care Services.

Note: For DAHS, Form 2060 and Task/Hour Guide are not required.

Form 2059; Provider Referral Supplement;
Form 2060; Task/Hour Guide; and authorization Form 2101.

Form 2059; Provider Referral Supplement; and
Form 2101 as an authorization.

Authorization Form 2101;
Form 2327, Individual/Member and Provider Agreement;
Form 2330, Assessment and Service Plan Approval for Adult Foster Care.

Annual Reauthorization and Interim Reassessment Packet Forms

Must include a cover sheet and a copy of the following SASOW generated forms.

Community Attendant Services (CAS)
Primary Home Care (PHC)
Day Activity and Health Services (DAHS)
DAHS Facility -Initiated Referrals		 Family Care (FC)
Residential Care (RC)		 Emergency Response Services (ERS)
Home Delivered Meals (HDM)		 Adult Foster Care (AFC)

Even if there is not a change for CAS send:
Form 2101

(For DAHS and PHC only send Form 2101 if there is a change with appropriate forms)

Only if information has changed send:

Form 2059;
Provider Referral Supplement;
Form 2060; and
Task/Hour Guide.

Note: For DAHS, Form 2060, and Task and Hour Guide are not required.

Only if information has changed send:

Form 2059;
Provider Referral Supplement;
Form 2060;
Task/Hour Guide; and
Form 2101

Only if information has changed send:

Form 2059;
Provider Referral Supplement;
Form 2060;
Task/Hour Guide; and
Form 2101

Even if there is not a change send:

Form 2101; and
Form 2330

Only if information
has changed send:
Form 2327

Termination Packet Forms

Must include a cover sheet and a copy of the following SASOW generated forms.

Community Attendant Services (CAS)
Primary Home Care (PHC)
Day Activity and Health Services (DAHS)
DAHS Facility-Initiated Referrals

 Family Care (FC)
Residential Care (RC)		 Emergency Response Services (ERS)
Home Delivered Meals (HDM)		 Adult Foster Care (AFC)
Authorization Form 2101 Authorization Form 2101 Authorization Form 2101 Authorization Form 2101

Note: In the SASOW, the following forms are generated as two forms:

  • Form 2059 is generated as Form 2059 and the Provider Referral Supplement.
  • Form 2060 is generated as Form "2060 and the Task/Hour Guide."