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Effective Date: 




Updated: 9/2017



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.


Detailed Instructions

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.