Case Management Resources

Tribal ALTCS Programs shall establish a system of record keeping that maintains case file documentation in a secure and organized manner. Case Managers are responsible for maintaining complete and comprehensive case file documentation for each member. Below are forms utilized by Tribal ALTCS Case Managers.

• ALF Residency Plus Room & Board Calculation Sheet 2020
• Exhibit 1620-2, ALTCS Member Change Report
• Exhibit 1620-3, Uniform Assessment Tool and Guidelines
• Exhibit 1620-7, Fee-For-Service (FFS) Out-of-State Nursing Facility Placement Request Form
• Exhibit 1620-8, Contractor Change Request Form
• Exhibit 1620-9, ALTCS Enrollment Transition Information (ETI) Form
• Exhibit 1620-12, Spouse Attendant Care Acknowledgement of Understanding Form
• Exhibit 1620-13, ALTCS Member Service Plan
• Exhibit 1620-14, ALTCS Member Contingency Back-Up Plan
• Exhibit 1620-15, Assisted Living Facility (ALF) Residency Agreement
• Exhibit 1620-16, Assisted Living Facility (ALF) Financial Change Agreement
• Exhibit 1620-17, HCBS Member Needs Assessment