SECTION 1. Managed Care Plan Information
SECTION 3. Acknowledgement / Release of Medical Information
I understand:
That I must join a Managed Long Term Care Plan (MLTC Plan) to receive Medicaid community-based
long term care (cbltc) services in my county.
The differences between a Medicaid health plan and a MLTC Plan and that I will lose some benefits.
I may not be able to see my doctors if I change to a MLTC Plan.
The Conflict Free Evaluation and Enrollment Center (CFEEC) must determine I need more than 120
days of cbltc services and that I am nursing home eligible, before I can join a plan. A CFEEC nurse will
contact me to schedule an evaluation.
I give my Provider permission to give all needed medical information only if it is relevant to my request
to transfer to a long term care plan. This may include any disability information needed to confirm
needed services that are not available in my Medicaid health plan.
Medicaid health plan you are in now: _________________________________________________________
MLTC plan you are transferring to: ___________________________________________________________
CFEEC Evaluation Request Form
Plan Member Date
Authorized Representative’s Signature
q q
Male Female
Last Name First Name Middle Initial Date of Birth (mm/dd/yyyy)
Medicaid ID Gender Telephone Number (with Area Code) Cell Phone (with Area Code)
Permanent Address City
County State Zip Code Email Address
Last Name First Name Middle Initial Relationship to Member
Address City County State Zip Code
Telephone Number (with Area Code) Cell Phone (with Area Code) Email Address
SECTION 2. Plan Member Information
For Mainstream plan member requiring
non-covered LTC benefits
SECTION 4. Physician Authorization
A Physician must fill out this Section including the Provider Information/Signature Box listed below.
I __________________________________ hereby confirm that ___________________________________
requires the service/services listed below which makes him/her a candidate to transfer
from a Medicaid Health Plan to a Managed Long Term Care Plan.
4a. Please add check mark 3 to all that apply.
q Environmental Modification: Internal and external physical adaptations to the home, which are
necessary to assure the health, welfare, and safety of the individual, enable the individual to
function with greater independence in the home, and prevent institutionalization.
q Home Delivered Meals
q Social Day Care
4b. Provider Information/Signature
Physician Name
Patient Name
Physician Name: _________________________________________________________________________
Specialty: _______________________________________________________________________________
License #: ______________________________________________________________________________
Name of Clinic/Facility: ___________________________________________________________________
Address: ________________________________________________________________________________
City: _________________________________________ State: _______ Zip Code: ___________________
Phone: ______________________________________ Fax: _____________________________________
Signature (sign digitally): __________________________________________________________________
Provide the name of the MLTC Plan representative who is submitting this form
on behalf of the applicant.
Plan Representative:
Name: ___________________________________________________________________________________
Title: ___________________________________________________________ Date: ___________________
Signature: _____________________________________________ Phone Number: ___________________
SECTION 5. Managed Long Term Care Plan (MLTC Plan)
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