PublicReferralForm - GCL Application

Gateway to Community Living
Referral Form

This form can be used by individuals currently living in a nursing home, or their representatives, to request information about Medicaid services available to assist in returning to community living. Please fill in as much of the information requested below as possible.

This information will automatically be sent to the facility, as this will help us respond more quickly to your request. If you would prefer that it didn’t, please check the box at the bottom of the page.

(*) Required fields

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Today's Date:

11/21/2019

Name of Person Residing in Facility:

First Name *

Middle Name

Last Name *

Date of Birth

mm/dd/yyyy

Phone Number

Does the Person currently receive Medicaid? * Yes No Don't Know If yes, please provide the Medicaid Number, if known.

Where does Person live now?

Facility Name *

If other, enter Facility Name *

Admission Date to this facility
	mm/dd/yyyy

Facility Contact Person
First Name of facility point of contact.	Middle Name of facility point of contact.	Last Name of facility point of contact.

Facility Contact Phone Number

Address of referred person.	Apt/Suite of referred person.
City of referred person.	State of referred person.
Zip Code of referred person.	County of referred person.

Name of Person Making Referral / Advocacy Organization
Relationship *

Organization Name/Relationship *

First Name *

Middle Name

Last Name *

Phone Number *

Address

Apt/Suite

City

State

Zip Code

County

Who Should We Contact to Provide Information About Gateway to Community Living? *

Individual Person Making Referral Other

If Other, provide information below:

Relationship *

Organization Name/Relationship *

First Name *

Middle Name

Last Name *

Phone Number *

Address

Apt/Suite

City

State

Zip Code

County

I do not want this to go to the Nursing Home.

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