S
W-1531
(Rev. 6/06)
tate of Connecticut
Department of Social Services
CONNECTICUT HOME CARE PROGRAM FOR ELDERS
Potential Discharge Recommendation Due to
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. |