SPEED REFERRAL for
Community Alternatives Program for Disabled Adults (CAP/DA)
This form is intended to facilitate the referral process that you, as a professional, are undertaking on behalf of your client.
For the CAP program, your client must be a resident of Wake County, 18+ years of age, at a nursing home level of care, at risk for nursing home placement related to care needs, and eligible for Medicaid. An Intake specialist, who can be reached by calling 919-872-7933, can assist you in screening your client if you are unsure whether yours would be an appropriate referral.
HINT: Use your mouse or tab key to move from one field to another. Using the Enter/Return key will cause the form to be submitted prematurely!
|Date of Birth:|
|SSN:||Please call RFS Intake with this info -- 919-713-1556. This referral will not be entered on the wait list until we receive this information.|
|Caregiver or Contact Name:|
|Address(if different from above):|
|# living in home:|
|Monthly Income of the Client ONLY:|
|Physician Phone #:|
|Does client have Medicaid already?|
|If so, Medicaid #:||Please call RFS Intake with this info -- 919-713-1556|
Anything else we should know? Who should we contact, client or caregiver?
Are there other contact people we should know about? Any communication barriers?
By making this referral, you are certifying that the above information is correct to the best of your knowledge, and that the client is aware of your actions on his/her behalf and has been notified of the waiting list for this program. If you have any questions related to this referral, please call an Intake Specialist at 919-872-7933.
|Phone# where message can be left for you (no pagers accepted):|
How did you hear about RFS/CAP?