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Temporary Hotel Assistance Request * T19 and NT19 SMI adults

* Send request to smimemberservicesrequest@MercyCareAZ.org

Name: AHCCCS ID#: Agency: CM: Level of CM service (i.e. ACT, Supp): Date of check in:

Date of request: Date service needed: DCC site: VI-SPDAT score: T19/NT19: Date of check out:

Amount requested:

To best assist in reviewing request, provide the following information:

1) Living situation prior to transition setting:

2) Transition setting where the member iscurrently residing (if applicable):

• If “Other,” identify location:

3) Identified living situation post hotel stay:• Estimated date of move in:

4) Does member have a valid Arizona ID? (If so, provide a copy)

5) Identify support service and date referral sent:

Reason for request:

What current support is provided to the member (include informal and formal supports)?

What support will be provided to the member during the hotel stay? Are supports currently in place or will be in place by check in time?

SA/CD signature Date

RD signature Date

Attestation: By signing the above application for hotel assistance, I certify that to the best of my knowledge, information and belief, that the information contained in the application for hotel assistance concerning the functional area for which I am accountable, is accurate, complete, and truthful.

Updated 07/01/18