Forms

The Department of Elder Affairs (DOEA) and aging network partners use a suite of screening and assessment forms to determine the needs of prospective and existing clients. 

Various professional types use these forms to collect data for the purposes of: 

• Determining nursing home level of care; 
• Identifying the needs and resources of individuals seeking publicly-funded supports and services; 
• Reporting demographic information to federal partners; and 
• Reassessing clients to maintain their eligibility for services. 

Thank you for your input! 

The Department collected feedback on the current 701 suite of forms through a survey that closed October 19, 2018. Thank you to all respondents for your valued feedback. 

Descriptions and Links 

701B Comprehensive Assessment 

This form is a comprehensive assessment to be administered face-to-face to identify resources and deficits in case-managed clients. 

701A Condensed Assessment 

This form is a shortened assessment instrument that is administered face-to-face for non-case managed clients in general revenue local services programs and federal OAA programs. 

701S Screening 

This form is administered over the telephone for the initial screening of applicants for long-term care programs. It is also used as an enrollment management tool to re-screen individuals on the assessed priority consumer list (APCL) and not active in any program. 

701C Congregate Meals Assessment 

This form is used to assess individuals for congregate meals and nutrition counseling services in the OAA Title C1 program. 

701T Non-Community Placement Assessment 

This form is a shortened assessment instrument designed for use by CARES staff in determining level of care for individuals with no intent or capacity to remain in, or return to, the community. 

DOEA screening and assessment forms: 

• 701A Condensed Assessment (English; Spanish) 
  Shortened assessment instrument based upon the 701B Comprehensive Assessment to be administered face-to-face for non-case managed clients in Local Services Program and OAA programs. 
• 701B Comprehensive Assessment (English; Spanish) 
  A comprehensive assessment that is administered face-to-face to assess all case-managed clients regardless of the program in which they are enrolled. 
• 701C Congregate Meals Assessment (English; Spanish; Scorable Version) 
  Shortened assessment instrument used to assess individuals for congregate meals and nutrition counseling services in the OAA Title C1 program. 
• 701S Screening Form (English; Spanish) 
  This form is administered over the telephone for the initial screening of applicants for long-term care programs. It is also used as an enrollment management tool to re-screen individuals who are on a waiting list and not active in any program. 
• 701T Non-Community Placement Assessment 
  Shortened assessment instrument for use by CARES staff for individuals residing in a nursing facility with no intent to return to the community or for individuals residing in the community intending to enter the nursing facility. 

DOEA assessment form instructional materials: 

• 701B Comprehensive Assessment Form Online Training 
  Before administering the new assessment and screening forms, except the 701C, assessors and case managers must complete this online training and retain a certificate to demonstrate that they successfully passed the final examination. For helpful tips on how to avoid common mistakes when completing the 701B assessment, please see the presentation video at the following link: 701B Training Video 
• 701C Congregate Meals Assessment Training 
  Training information for the 701C Congregate Meals Assessment. 
• 701D Assessment Instructions 
• DOEA Priority Score Calculation 
• Guidance for completion of the Department of Elder Affairs 701B Comprehensive Assessment. 

AHCA 5000-3008 (JUN 2016) 

The AHCA 5000–3008 form is used by the Comprehensive Assessment and Review for Long-Term Care Services (CARES) Program to help determine medical eligibility for Medicaid Waiver programs. This form must be signed by a licensed physician, physician assistant, or advanced practice registered nurse. If not licensed in Florida, verification of their appropriate medical license must be provided. 

• Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form – AHCA 5000-3008 (JUN 2016) 
• AHCA 5000-3008 Referral Cover Sheet 

Informed Consent Form 

This form provides consent for CARES to perform an assessment evaluating need for long-term care. 

• Informed Consent – English 
• Informed Consent – Spanish 
• Informed Consent – Creole 

Notice of Privacy Practices 

This notice applies to the information and records we have about your health, health status, and the health care and service you receive from the Department in your personal file. 

• Department of Elder Affairs Notice of Privacy Practices – English 
• Department of Elder Affairs Notice of Privacy Practices – Spanish 
• For more information on the Department of Elder Affairs’ HIPAA (Health Insurance Portability and Accountability Act) Privacy Policies and Procedures 

Social Security Number Notice 

This notice explains why the Department of Elder Affairs is collecting your Social Security number. 

• Department of Elder Affairs Social Security Number Notice – English 
• Department of Elder Affairs Social Security Number Notice – Spanish