(Revised 7/1/15 ML #3460)
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Purpose: To provide evidence an applicant is eligible for the Expanded SPED (ExSPED) program. This form, SFN 56, is forwarded to the Medical Services Division, along with the SFN 676, in order to enter the applicant into the ExSPED pool and to assign a recipient identification number.
Social Security Number: Enter applicant’s SSN
Check Here if Person Lives Alone: If the person lives alone or has minor children or the other family member(s) in the house are physically or mentally unable to assist the client, check the box.
Last/First Name: Print the name of the applicant
Birth Year/Birth Month/Birth Day: self-explanatory
Sex: If the applicant is a male, record a 1 in the box; if female – record a 2
ADLs: Based on the functional assessment, transfer the scores from the assessment document to the applicable score box. If the applicant is eligible for the ExSPED program, the applicant cannot be severely impaired in the ADL’s of toileting, transferring, or eating impairments (which means the applicant cannot have a score of 3 in these activities).
IADLs: Based on the functional assessment, transfer the scores from the assessment document to the applicable score box. If the applicant is eligible for the ExSPED program based on IADLs, the applicants IADL score fields will reflect impairments of Meal Preparation, Housework, Laundry, and/or Taking Medications with a score of one or two in three of these IADLs.
Cost of Service Estimated Monthly Dollars: Record the estimated dollar amount per service that will be anticipated as an authorized service.
Case Manager, County Number: Record the Case Manager’s name and County.
The form, SFN 56, is not available from the state office. It is available through the state electronic e-forms.