Cltc referral 2026

1. Click ‘Get Form’ to open the cltc referral application in the editor.
2. Begin by selecting the reason for referral. Circle the appropriate program from options such as Pre-Admission Review, Nursing Home Conversion, or Community Choices Waiver.
3. Fill in the applicant information section. Provide details like first name, last name, permanent address, and contact numbers.
4. Complete the demographic data by circling the appropriate categories for gender, marital status, race, education level, and primary language.
5. In the present location section, enter the name and address of the facility where the applicant is currently located.
6. Identify a contact person by providing their name, relationship to the applicant, and contact information.
7. Circle any functional dependencies that apply to the applicant's needs in the reason for referral section.
8. Finally, complete the referral source section with your details and sign at the bottom before submitting.

Start filling out your cltc referral form online for free today!