Independent Lifestyles, Inc. Admission Form and Data Sheet

Personal Information Name: _______________________________________________ Date of Birth: ____________________

Social Security Number (SSN): ______________________________________ Gender: _________________________ Street Address: _____________________________________________________________________________________

City, State & Zip Code: _______________________________________________________________________________

County: __________________________ Marital Status: ___________________ Diagnoses: _________________

Home Telephone Number: ___________________________________ Cell Phone Number: ______________________

Email Address: _____________________________________________________________________________________

Language(s) spoken: _________________________________________________________________________________

Guardianship type (self, private, public): _________________________ Veteran? Yes No

Do you currently have a Rep-payee? Yes No Name/Phone ___________________________________________ If yes, please state the reason for the change:

___________________________________________________________________

Ethnicity (check all that apply) American Indian/Alaskan Native Asian Black/African American Native Hawaiian/Other Pacific Islander Hispanic/Latino White

___________________________________________________________________

Housing Status Homeless Adult Foster Care Dependent-Family/Friends Independent Rent-Subsidized Rent-Unsubsidized Assisted Living

___________________________________________________________________ Employment Status

Unemployed Sheltered Supported Transitional Internship (paid) Part-Time (competitive) Full-Time (competitive) Retired Not Employed (seeking employment) Not Employed (not seeking employment)

Education Level

Below 12th Grade High School Diploma/GED Trade/Vocational Some College Bachelor’s Degree Master’s Degree Doctorate Degree

___________________________________________________________________

General Contact Information

Full Name (First/Last) Email/Phone Number/Address Legal Representative: _______________________________ _______________________________________________ Authorized Representative: __________________________ _______________________________________________ Primary Emergency Contact: _________________________ ________________________________________________ Residential Contact: ________________________________ ________________________________________________ Family Member: ___________________________________ ________________________________________________ Case Manager: ____________________________________ ________________________________________________ Financial Worker: __________________________________ ________________________________________________ Vocational Contact: ________________________________ ________________________________________________ Other Service Provider: _____________________________ ________________________________________________

___________________________________________________________________

Health Related Contact Information

Full Name (First/Last) Address and Phone Numbers Primary Health Care Professional: _________________________________ ________________________________________________ Psychiatrist: ______________________________________ ________________________________________________ Pharmacy: ________________________________________ _______________________________________________ __________________________________________________________ _________________________

Person served or legal representative Date

ILICIL’s SSA – Information Sheet

Name: _________________________________________________________ Date: __________________________

Please list any other names you have gone by _____________________________________________________

Place of Birth- ___________________________________________Mother’s Maiden Name ______________________ (County, City, State)

Have you ever been married? Yes No If divorced, when was your divorce? ______________________

____________________________________________________________________________ Are you working? Yes No Name of employer _________________________________________________ Address __________________________________________________________ Phone __________________________

_____________________________________________________________________________ Do you have a separate bank account, in addition to the one Independent Lifestyles uses? Yes No Checking- Yes No Amount _________________ Savings- Yes No Amount ___________________ Name and address of Bank ___________________________________________________________________________

_____________________________________________________________________________ Do you have any of the following types of resources? How often received (weekly, bi-weekly, monthly)

VA Benefits Yes No Amount __________ How often received ______________ Cash Assistance Yes No Amount __________ How often received ______________ Child support Yes No Amount __________ How often received ______________ MFIP Yes No Amount __________ How often received ______________ Pension Yes No Amount __________ How often received ______________ Life insurance policy Yes No Amount __________ How often received ______________ Special needs trust fund Yes No Amount __________ How often received _______________ Retirement Account Yes No Amount __________ How often received ______________ Burial Account Yes No Amount __________ How often received ______________ Tribal benefits Yes No Amount __________ How often received ______________ Supplemental Security Yes No Amount __________ How often received ______________ Income (SSI) Retirement, Survivors, Yes No Amount __________ How often received ______________ Disability, Insurance (RSDI, SSDI) Other __________________ Yes No Amount __________ How often received ______________

Do you own anything that can be converted to cash, such as but not limited to, rare coin collection, collector car, farm equipment, second vehicle etc.? Yes No

If yes, please list item ________________________________________________ Value ___________________ What is the amount of cash you have available? __________________________________________________________ Do you own a vehicle? Yes No Make __________________ Model _______________ Year ____________ Purchase price or value ______________

_____________________________________________________________________________ Do you have a guardian? Yes No Does the guardianship include Conservatorship? Yes No

Name __________________________________________________ Phone _____________________________ Address ___________________________________________________________________________________________ Do you have children? Yes No Name ____________________________ Date of birth ______________ Are they receiving benefits? Yes No Name ____________________________ Date of birth ______________ Are they receiving benefits? Yes No

_____________________________________________________________________________ Have you been convicted of a felony? Yes No

If yes, When? ___________________________ Why? _____________________________________________ Have you been out of your home for more than 30 days in the past year? (jail, hospital, treatment facility, etc.)

Yes No When? ___________________ How long? _________________________________ If yes, Name of Facility _______________________________ Address ________________________________________ Have you moved in the last 3 years? Yes No Date of move _____________Prior Address _____________________________________________________________ What is your current address? _________________________________________________________________________

Is it a Group Facility- Yes No

If yes, name of facility _________________________________________________________________________ Homeless: Yes No House/apartment: Yes No Name of Roommate _________________________________________

Name of Apartment Complex ___________________________________________________________________ Who helps you fill out paperwork? ____________________________________________________________________

Independent Lifestyles, Inc. (Check One) ___ (IA) Date: ________

___ (AA) Date: ________

DPF-010 Rev 7/8/2019 1

STANDARD RELEASE OF INFORMATION

Name: Date:

I, hereby, authorize Independent Lifestyles, Inc. to release/obtain information to my support team and/or expanded

support team as needed, including my county case manager, county financial worker, and other licensed service providers

that fall under any identified agencies listed below.

I understand the purposes for collecting and releasing my private information. I also understand that the

information released by Independent Lifestyles will be used only by authorized agencies or entities. The MN Government Data Practices Act protects your privacy, but also lets us release information about you to others if

1) a law or government regulation requires it and 2) we tell you before we do it.

What are some reasons we use your information? There are many reasons we use your private information regarding service provision and continuity of care purposes.

Your information allows us to tell you from other persons who get the same service; to understand what services you may

need; deliver those services in the most effective and efficient way possible, to work efficiently and effectively with other

organizations or people who also support you; to protect your rights; collect money from the federal, state, or county

agencies for services provided; to make reports, audit, and evaluate our services to make them better; and/or to ensure that

our services are designed and delivered in accordance with all federal, state, or county laws and regulations.

Who else may access your information when required? The following entities also have access to persons’ private data as authorized by applicable state or federal laws,

regulations, or rules. Other entities or individuals authorized by law:

Minnesota Department of Human Services County of financial responsibility

County of company’ social services Local or state health departments

U.S. Department of Health and Human Services Law enforcement personnel and attorneys Social Security Administration Various state departments Federal, state, or county auditors Representative payee and financial workers Adult or Child Protection units and investigators Other licensed service providers as needed

The MN Ombudsman for Mental Health or Developmental Disabilities

Agents of the welfare system or investigators

You have the right to access your information and to request copies.

You and/or legal representative have the right to request that your records or recorded information and documentation be

altered and/or to request copies. If you would like copies of your information, please provide us with five (5) days notice.

Information will be disclosed to appropriate parties in connection with an emergency if knowledge of the information is

necessary to protect the health or safety of the person served or other individuals or persons. Information will be

maintained on this disclosure and you may request this information and request copies.

What can you do if you believe your information is inaccurate?

Your objections must be in writing and submitted to Independent Lifestyles. This written notice must include why you

believe the information is incorrect. Please include an explanation of the information that you disagree with. A copy of the

objection you submitted in writing will be maintained in your service recipient record. Your explanation will be attached

any time that information is shared with another agency.

What privacy rights do minors have?

If you are under eighteen (18), your legal representative/legal guardian may see data about you and authorize others to see

it. You can make a request to have specific information withheld from people with whom you do not want your

information shared. Your legal representative/legal guardian will make a determination if the information will be shared.

Independent Lifestyles, Inc. (Check One) ___ (IA) Date: ________

___ (AA) Date: ________

DPF-010 Rev 7/8/2019 2

Summary/consequences – I know that state and federal privacy laws protect my records. I know:

Why I am being asked to release this information.

I do not have to consent to the release of this information. But not doing so may affect Independent Lifestyles’

ability to provide needed services to me.

If I do not consent, the information will not be released unless the law otherwise allows it.

I may stop this consent with a written notice at any time, but this written notice will not affect information

Independent Lifestyles has already released.

The person(s) or agency(ies) who receive(s) my information may need to pass it on to others.

If my information is passed on to others by Independent Lifestyles, it may no longer be protected by this

authorization.

This consent will end in one annual year from the date I sign it, unless the law allows for a longer period.

I understand that without my prior, written consent, the sharing, sale or use of my information will not occur for any

purpose with any agency not listed above, for any reason not described above, or for any use not described above. I

understand that I also have the right to review any information which is maintained by Independent Lifestyles, Inc.

about me, as provided for in MN Government Data Practices Act, section 13.46. I further understand that I may review

the information before it is released, subject to my right to review this information under the controlling federal and state

laws. We will notify you if a breach occurs. If you have questions or would like more information you may contact our

Compliance Office, Danelle St. Marie, at 320-529-9000. If you believe your privacy rights have been violated, you can

file a complaint with the Disability Law Center at 1-800-292-4150. There will be no punishment for filing a complaint.

This consent expires on (may not exceed one year):

____________________________________________ ________________________________

Person served/ legal representative signature Date

Independent Lifestyles, Inc. (SI) Date: ________ (AA) Date: ________

DIF-024 Rev 1/5/18 1

RIGHTS OF PERSONS SERVED Name: Date: Application and intent of these rights Independent Lifestyles will ensure that the person’s rights in the services provided by Independent Lifestyles are exercised and protected by all staff of Independent Lifestyles including subcontractors, temporary staff, and volunteers. This document will be signed and dated by the person served and/or legal representative and maintained in the service recipient record at service initiation. Service-related rights 1. Participate in the development and evaluation of the services provided to the person.

2. Refuse or terminate services and be informed of the consequences of refusing or terminating services.

3. Know, in advance, limits to the services available from Independent Lifestyles, including IndependentLifestyles’ knowledge, skill, and ability to meet the person’s service and support needsThose limits are: Independent Lifestyles’ does not do taxes, give legal advice, counseling, and/or therapy.Independent Lifestyles does not provide emergency/crisis services, housing, medical advice or services, or havemoney to give to the consumer from the agency. Independent Lifestyles will only transport persons served as a lastresort in designated programs and pre-approved by the Designated Manager.Independent Lifestyles’ knowledge, skills, and ability to meet your service and support needs include: IndependentLifestyles staff is trained to meet program needs.

4. Know what the charges are for services, regardless of who will be paying for the services, and be notified uponrequest of changes in those charges.

Protection-related rights 1. Have personal, financial, service, health, and medical information kept private, and be advised of disclosure of

this information by Independent Lifestyles.

2. Access records and recorded information about the person in accordance with applicable state and federal law,regulation, or rule.

3. Be free from maltreatment. You have the right to live without fear of abuse, neglect, or financial exploitation. If anyof these were to occur, Independent Lifestyles has policies and procedures in place to help protect your ongoing safetyand the safety of others. If you choose to make a vulnerable adult report on your own you can call the MN AdultAbuse Reporting Center (MAARC) at 1-844-880-1574.

4. Be treated with courtesy and respect and receive respectful treatment of the person’s property.

5. Reasonable observance of cultural and ethnic practice and religion.

6. Be free from bias and harassment regarding race, gender, age, disability, spirituality, and sexual orientation.

7. Be informed of and use Independent Lifestyles consumer complaint procedures, including knowing how tocontact persons responsible for addressing problems and to appeal.At any time, you may contact your legal representative, case manager, an advocate, or someone within IndependentLifestyles if you are not satisfied with services being provided in order to make a formal complaint. The consumercomplaint procedures will be followed and all complaints will be taken seriously with the intention of a beneficialresolution to the issue.

__________________________________________ ___________________________________ Consumer/ Legal Rep Signature Date

Independent Lifestyles, Inc. (Check One) (IA) Date: (AA) Date:

SPECIFIC RELEASE OF INFORMATION

Name: Date:

In order to provide services to you Independent Lifestyles may need to obtain information from or share information with

other individuals, programs, or providers. If Independent Lifestyles does not get requested information, or if we cannot

share with others who work with you, then Independent Lifestyles might not be able to provide you services you may

need or Independent Lifestyles’ assistance may be hindered.

I, (name of person/legal representative)

Authorize Independent Lifestyles to release/obtain information to/from (i.e. utility company, community agency,

counselor, therapist, relative, friend, housing, employer) ** Only list one entity per form and do NOT list any entity

already listed on Standard Release of Information or guardian/legal representative**:

Indicate the type of information that will be released/obtained (i.e. bank statements, health diagnosis, medical records,

personal information):

For the purpose of: providing Independent Lifestyles services to the consumer.

This information will be used for:

Payments Services/continued care Consumer’s request Case notes Other (please explain):

I understand that only the information described above will be released to this entity and that it will be used solely for the

purpose described above. It will not be disclosed to any other source unless specifically authorized by me. I have been

informed that I may refuse to authorize the release of this information and the consequences of such a refusal have been

explained to me.

This consent expires on (may not exceed one year):

Person/ legal representative signature Date

DPF-011 Rev 11/24/14 1

Independent Lifestyles, Inc. Representative payee program

_________________________________________________________________________________________________

CONSUMER MONTHLY BILLS WORKSHEET Please indicate below what the expense is (Rent, Electricity, Home, or Cell Phone, Cable/Satellite etc.)

Expense:_________________________ Amount: $___________________

Payable to:_____________________________________________________

Amount: $___________________ Expense:_________________________

Payable to:_____________________________________________________

Amount: $___________________ Expense:_________________________

Payable to:_____________________________________________________

Amount: $___________________

Expense:_________________________

Payable to:_____________________________________________________

Expense:_________________________

Payable to:_____________________________________________________

Amount: $___________________

Please use additional sheets if needed

  

  

Designation of Beneficiary for my Independent Lifestyles accounts  

Date: _______________________        SSN: __________________________  Name: ________________________________________   Date of Birth: ___________________        I, __________________________, cancel any and all previous designations of beneficiaries made by me regarding my independent lifestyles accounts. I am naming the beneficiary (s) listed below to receive any benefits saved in my independent lifestyles accounts, payable after my death.   Information concerning beneficiaries: Name      Address/Phone              Relationship    Amount to be paid (%) 

     

   

     

   

     

   

     

   

 Total__________% 

 ______________________________          ________________     Signature                Date ______________________________          _________________ Independent Lifestyles Inc.  Staff           Date ______________________________          _________________ Witness                 Date 

Representative Payee Services Policies & Procedures

Social Security benefits will be used to address needs in the following order:

1. Basic needs (food, shelter, utilities) 2. Medical and dental needs not covered by health insurance 3. Personal needs (clothing, recreation, vehicles)

Process to obtain a Representative Payee through Independent Lifestyles:

1. Complete intake packet and submit to ILICIL. This is done to get a clear financial picture of the needs and obtain proper releases and important information.

2. After intake paperwork is completed and submitted to ILICIL, staff will submit an application to be Representative Payee to the Social Security Administration.

3. Once approved for rep payee services, a representative will contact the consumers/Guardian and develop a budget based on consumer’s needs.

4. Staff and consumers/guardian will maintain ongoing communication regarding changes in financial obligations and to update any necessary paperwork.

Ways to contact your Representative Payee: 1. Independent Lifestyles has a voicemail system where you can leave a message for your Rep-payee.

Please leave no more than one message per day and your message will be returned as soon as possible. When leaving a message state your name, best way to get a hold of you, phone number/email and a detailed reason for your call.

2. Independent Lifestyles has an email address where you can send emails to your Rep-payee. That Email is: Reppayeeteam@independentlifestyles.org

3. You may make an appointment to meet with your representative payee. You can schedule an appointment by contacting the Rep-payee team. Walk in appointments will not be scheduled.

4. Independent Lifestyles has a walk in service called Real-Time Resources. These walk in times are scheduled monthly and consumers can walk in anytime during set hours and ask questions about their finances, SSA or county paperwork, or obtain other assistance with community resources.

Monthly Budgets/Personal needs:

1. Staff will create a monthly budget for you, based on the information you provide when approved for services. Budgets will emailed if you provide an email address, or available for pick up monthly, as requested. Please note you are responsible to review your budget and notify staff of changes.

It is important to notify your representative payee by phone or email before the last day of the month if you are planning on moving the following month. If you fail to do so, your rent check might not be paid correctly.

2. Independent Lifestyles requires a copy of a rental agreement and bills you would like paid. If you do not provide a bill, it will not be paid. No exceptions.

3. Independent Lifestyles distributes personal needs money on Fridays only, any changes to personal needs for Friday need to be requested by 4:30 pm Wednesday.

4. Personal needs can be scheduled in your monthly budget. If you have additional needs after your budgeted expenses are met, you may request to have a portion of those funds issued to you.

Any personal needs requested over $300.00 must be discussed with the Rep-payee team, and you could be asked to put your request in writing.

You must give at least 48 hours to process your request. It is not possible to approve requests immediately.

You are required to submit receipts to show how excess funds were used. 5. Each consumer has the option to have their personal needs direct deposited into their personal bank account or

use Independent Lifestyles issued Focus cards. Additional information/policies:

1. Independent Lifestyles is not responsible for any lost or stolen checks. In order to void a check back into the account, Independent Lifestyles requires the original check to be returned. Without the original check being returned, Independent Lifestyles must wait 1 year in order to void any uncashed checks back into the account. If you wish to stop payment on any checks you will be responsible for the stop payment fee.

2. We reserve the right to terminate payee services if you are verbally or physically abusive, damage Independent Lifestyles property, appear to be chronically intoxicated or under the influence of drugs.

3. Consumers/Guardians have the right to terminate services at any time. Independent Lifestyles is required to send any money in your account back to SSA. If you choose to end services, money in your account will not be issued to you.

4. I understand that Independent Lifestyles will not post bail if I am arrested.

5. Independent Lifestyles will not be held responsible for any overpayments due to your failure to notify our

office of changes. Notification of changes (wage change, job change, change in residence, etc.) must be in writing. This can be done in person, fax, email or mailing a signed letter to Independent Lifestyles.

6. I agree to provide Independent Lifestyles information about any other bank accounts that I hold in order to verify assets. I will send in verifications on a monthly basis. I understand failure to do this may result in SSA overpayments and/or loss of my benefits.

7. Independent Lifestyles collects a monthly Rep Payee fee and this will be deducted from your benefits each month. The Rep Payee fee amount is determined by the Social Security Administration.

8. Failure to follow any of these policies/procedures may result in termination of services or suspension of benefits.

I have been made aware of these Policies & Procedures. I understand them and agree to follow them.

______________________________ _____________________ Consumer/ Legal Guardian Signature Date