Form 1044 is used by a local intellectual and developmental disability authority (LIDDA) habilitation coordinator to document an individual’s refusal of habilitation coordination.
When to Prepare
Form 1044 is prepared when an individual who is eligible for habilitation coordination refuses habilitation coordination.
The original completed form is maintained in the LIDDA’s record for the individual. A copy of the completed form is provided to the individual or legally authorized representative (LAR).
LIDDA Name — Enter the name of the LIDDA.
LIDDA Comp Code — Enter the LIDDA’s component code.
LIDDA Contact — Enter the name of the LIDDA staff who is responsible for taking calls from nursing facility residents who have refused habilitation coordination and who may subsequently want to receive habilitation coordination.
Area Code and Telephone No. — Enter the area code and telephone number for the LIDDA contact.
Individual Name — Enter the name of the individual who transitioned or diverted.
CARE ID — Enter the individual’s Client Assignment and Registration (CARE) System identification number.
Name of Legally Authorized Representative (LAR) — Enter the first and last name of the individual’s LAR, if one.
Date of Nursing Facility Admission — Enter the date the individual was admitted to the nursing facility.
Date of PASRR Evaluation (PE) — Enter the date the individual’s Preadmission Screening and Resident Review (PASRR) evaluation was entered into the Long Term Care online portal.
Date of IDT Meeting — Enter the date of the Interdisciplinary Team (IDT) meeting. The habilitation coordinator reads the narrative on the form to the individual and LAR.
Printed Name of Individual/LAR — Enter the name of the person who refused habilitation coordination, which is either the individual or LAR.
Printed Name of Habilitation Coordinator — Enter the habilitation coordinator’s name.
Habilitation Coordinator's Signature and Date —The habilitation coordinator signs and dates the form.
Habilitation coordinator must describe the reason the individual/LAR is refusing habilitation coordination here — Provide a brief description of the reason habilitation coordination was refused.