Connecticut home care program for elders potential Discharge Recommendation Due to




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S
W-1531

(Rev. 6/06)


tate of Connecticut

Department of Social Services


CONNECTICUT HOME CARE PROGRAM FOR ELDERS
Potential Discharge Recommendation Due to

Non-Payment of Client Contribution


TO: DSS/ACU Unit

FROM:      

(Access Agency or Assisted Living Service Agency - Location)
Client Name:       Client ID #:      

Past Due Amount: $       Date Past Due:      

The above named client is past due in making his/her client contribution of $       mo.

Date reminder was sent (15 days after due date - 1st attempt):    /    /     



(Month) (Day) (Year)
Date client was called (1st attempt):    /    /     

(Month) (Day) (Year)


Date family/caregiver was called (1st attempt):    /    /     

(Month) (Day) (Year)


Comments:      


     

Date family was contacted (2nd attempt):    /    /     



(Month) (Day) (Year)

Comments:      


     

Other Payment Sources Explored:      


     
     

Access Agency/



Assisted Living Services Agency Staff:          /    /     

(Month) (Day) (Year)

NOTE: Attach all documents supporting efforts made for collection of non-payment of client contribution.


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