Fillable AHVP Nursing Home Pilot Pre-Application The Alternative Housing

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AHVP Nursing Home Pilot Pre-Application The Alternative Housing

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The AHVP Nursing Home Pilot Pre-Application The Alternative Housing form is 2 pages long and contains:

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  • 13 check-boxes
  • 43 other fields

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AHVP Nursing Home Pilot Pre-Application
The Alternative Housing Voucher Program (AHVP) provides rental assistance vouchers to low income, non-
elderly persons with disabilities. The voucher provides a subsidy that can be used to rent a private market
apartment anywhere in Massachusetts. AHVP Participants receive one bedroom vouchers (except for an
appropriate reasonable accommodation). For more information on the Alternative Housing Voucher Program,
including general eligibility requirements you can visit https://www.mass.gov/service-details/alternative-
housing-voucher-program-ahvp or the CHAMP website, https://publichousingapplication.ocd.state.ma.us/ .
This pre-application is for a pilot program using 50 AHVP vouchers for residents of Skilled Nursing (SNF)
certified by Medicaid (MassHealth) who are eligible for AHVP to live in the community. If more than 50
eligible people apply, a lottery will be held to determine who will receive vouchers. If you are chosen, you may
be contacted by MassHealth to discuss transition options. To be eligible, you must be
- 59 years old or younger
- A person with a disability
- Low-income (as defined at this link: https://www.mass.gov/doc/ahvp-dmhrsp-income-limits-
2021/download . The lowest income limit across the state is currently $47,150 for a single person)
- Continuously residing in a skilled nursing facility from June 1, 2021 to July 15, 2021
This pre-application does not put you on any waiting lists for standard AHVP. If you would also like to be
added to a standard AHVP waitlist, you must do that through CHAMP or your local housing authority. If you
pass the pre-screening for this pilot and are chosen, you will then continue to the standard eligibility screening
process for AHVP.
Medicaid defines a skilled nursing facility as “A nursing facility with the staff and equipment to give skilled
nursing care and, in most cases, skilled rehabilitative services and other related health services” and skilled
nursing care as “care like intravenous injections that can only be given by a registered nurse or doctor.” You can
check if your place of residence is certified as a skilled nursing facility by going to
https://www.medicare.gov/care-compare/?providerType=NursingHome and entering the name and location of
your residence.
This application can be submitted online until July 15, 2021 at the following link: https://tinyurl.com/AHVPapp
You may also submit this application by mail by sending it to the following address:
Stavros, attn: AHVP pilot
210 Old Farm Road
Amherst, MA 01002
If sending by mail, it must be postmarked by July 15, 2021.
After submitting this application, it will be sent to the Center for Independent Living (CIL) in your area. They
will follow up with you to confirm receipt and possibly request more details, including verification of your
residence in a Skilled Nursing Facility. The following are equally acceptable forms of verification:
- A verifier fills out and signs the optional “verification” section on the pre-application. A verifier can be
your social worker, case worker, care manager, nursing home staff, a doctor, RN, or medical practitioner
- Letter or email from a verifier stating that you reside in a particular skilled nursing facility
- Signature of CIL employee who has personal knowledge that you are a nursing home resident
(“Personal knowledge” means that they have first-hand information such as having visited)
- MassHealth statement that establishes residence
This program is an equal housing opportunity. In Massachusetts, it is unlawful for a housing provider to discriminate against a current
or prospective tenant based on: Race, Color, National Origin, Religion, Sex, Familial Status, Disability, Source of Income, Sexual
Orientation, Gender Identity, Age, Marital Status, Veteran or Active Military Status, and Genetic Information.
AHVP Nursing Home Pilot Pre-Application
FIRST NAME: MIDDLE INITIAL: LAST NAME:
BIRTHDATE: E-MAIL ADDRESS: PRONOUNS:
TELEPHONE: VOICE TTY OTHER PHONE NUMBERS:
NAME OF SKILLED NURSING FACILITY WHERE YOU RESIDE:
ADDRESS OF FACILITY: CITY/TOWN:
STATE: ZIP CODE:
Is anyone helping prepare this pre-application? Yes No
If Yes: name and contact info of preparer:
PROGRAM QUESTIONS
Are you 59 years old or younger? Yes No
Are you a person with a disability? Yes No Unsure
Do you currently reside in a Skilled Nursing Facility? Yes No Unsure
If Yes: Admittance Date:
Do you have a disability for which you need an accommodation of an AHVP policy or procedure, or assistance completing this
application? Yes No
If Yes: please enter some additional details, attach additional sheet if necessary:
By my signature, I certify that the information I have given in this pre-application is true and correct. I understand that any false
statement or misrepresentation may result in the denial of my pre-application. I understand this pre-application is not an offer of
housing. I recognize that this information will be shared with the Center for Independent Living and MassHealth in my area, and
AHVP Administering Agency as appropriate, and agree they may contact me.
APPLICANT SIGNATURE DATE
PREPARER SIGNATURE (if applicable) DATE
Optional: Verification of residence in a Medicaid or MassHealth Certified Skilled Nursing Facility (SNF)
You may provide verification of your residence in an SNF by having a professional fill out and sign this portion of the form, as
described on the front page. You can also attach any other form of acceptable verification to this pre-application. If you do not include
verification with this pre-application, it will be requested later. Verification documentation must be received by the application
deadline for an application to be considered.
VERIFIER NAME: PREFERRED CONTACT:
Signatory is: (Check all that apply, include job title or other details if relevant)
Social worker, case worker, or nursing home staff
Doctor, nurse, or other medical provider
CIL Staff
Other:
Applicant currently resides in an SNF
Applicant does not currently reside in an SNF
I consent to be contacted by CIL staff with any further questions pertaining to verification of the applicant’s residence
By my signature, I certify that the information I have given in this section of the pre-application is true and correct. .
VERIFIER SIGNATURE DATE
For CIL Staff use
Date recieved:
Applicant’s residence in an SNF has been verified Not been verified
Eligibility notification date and method:
Name: Date
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AHVP Nursing Home Pilot Pre-Application The Alternative Housing

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Completed 7 July 2021

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