State of Alaska• Department of Health and Social Services
Senior and Disabilities Services
Re-Application for General Relief for
Assisted Living Home Care Benefits
Program Overview
The General Relief Assisted Living Home Care Program helps to pay for Assisted Living Home Care for
qualified Alaskans facing extreme financial crisis. This is a temporary benefit program. The General Relief
Program is a payer of last resort. Applicants must show that they have tried to obtain all other means of
payment including using their own resources and applying for Adult Public Assistance and Medicaid to pay for
necessary Assisted Living Home Care before the General Relief benefit can be used. This is a program paid for
through State of Alaska General Funds. The availability of this funding is subject to legislative appropriation.
A waitlist will be used when there is not enough funding to serve additional applicants.
Full program details including regulations and forms are posted on the Senior and Disabilities Services
General Relief Program website (http://dhss.alaska.gov/dsds/Pages/aps/apsrelief.aspx). General Relief
staff can be reached at 907-269-3666 or 800-478-9996 to answer questions about the program.
General Relief Assisted Living Home Care Defined
Assisted living care is a range of care which includes more than room and board, but which does not include
continuous nursing, medical care, or a secure setting. It encompasses twenty-four hour supportive and
protective services and assistance with activities of daily living and is provided in a residential environment
which encourages independent living to the extent possible for each resident (7 AAC 47.310). Residents may
leave the home as they wish and have the right to refuse medication or services.
General Relief Eligibility Criteria
The Division of Senior and Disabilities Services will pay for a portion of the cost of assisted living care for
vulnerable adults who meet the medical, social, and financial eligibility criteria outlined in 7 AAC 47.330
through 7 AAC 47.360. To be eligible, an individual must:
• Be 18 years of age or older;
• Be a resident of the State of Alaska;
• Have been assessed for eligibility by a care coordinator or other person approved by the Department of
Health and Social Services and:
• Have a disability that is attributable to an intellectual disability, cerebral palsy, epilepsy, autism or
another condition closely related to an intellectual disability that significantly impairs intellectual
functioning and adaptive behavior;
• Have a hearing, speech, visual, orthopedic, or other major health impairment that significantly impedes
participation in the social, economic, educational, recreational and other activities generally available to
the individual’s non-impaired peers in the community; or
• Have a significant deficit in adaptive behavior in the area of self-care, communication of needs,
mobility, or independent living, which may be the result of the aging process, an emotional health
disturbance, or alcohol or drug dependence;
• Without assisted living care, be subject to, or at risk of, abuse, neglect, self-neglect or exploitation by
others;
• Not have income that exceeds the limits permitted in 7 AAC 47.340;
GR-02 Re-Application for General Relief for Assisted Living Home Care Benefits
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Send Complete Applications
By E-mail via Direct Secure Messaging
By Facsimile: 907-269-3648
NOTE: Facsimile is the preferred
(DSM):
Note: You must enter the inpriva portal to
use this DSM e-mail address. Also you
mode of
transmission if there is
must have a registered DSM account to
By delivery or US mail:
Senior and Disabilities Services
General Relief
Assisted Living Home
Care Program
1835 Bragaw St. Suite 350,
Anchorage, AK 99508
not a registered
individual DSM
account.
send the application to this address. To
sign up for DSM please visit this website:
http://inpriva.com/inpriva/index.php/
• Not have resources that exceed the amount permitted by 7 AAC 47.350;
• Have applied for the cash assistance programs as required by 7 AAC 47.370(a); and
• Have applied for and exhausted the use of alternative resources.
Checklist
Please ensure all of the following items are complete and submitted as part of the same packet.
• Complete every part of every section of this form; if there is a part that does not apply, so indicate by
placing “N/A” in the blank; if there is a part where the information is not available, so indicate by
placing “unavailable” in the blank.
• Attach the most recent three months of bank statements
• Applicants claiming $0 income and/or those who are likely to qualify for Adult Public Assistance will
be required to attach proof that they have applied for Adult Public Assistance. The GR application will
not be considered complete without this documentation.
• General Relief will verify that the applicant either has or has not applied for public benefits.
• Applicant must complete the General Relief Contract on pages 9 and 10 of this form. The Applicant
must sign and initial this form in person; if the Applicant has a legal decision maker, attach the
documents that show the status of the legal decision maker, i.e., court order, signed power of attorney,
etc.
• Physician’s Report; pages 7 and 8 of this form; the physician’s report must be dated within 3 months of
this application.
• Submit a State approved form UNI-16 Authorization for Release of Information for each person or
agency, authorizing General Relief to discuss the application with someone other than the applicant,
referrer or legal decision maker.
Applications will be processed by the earliest date placed in the eligibility queue. If information is missing or
unclear, the application will be given a status of pending and a letter will be sent requesting the
information needed to determine eligibility. If the missing information is not received within 20 days of
the date on the letter, the application will be denied. SDS has 30 days to make an eligibility
determination once the application is complete. When a waitlist is in effect, the approval date is used to
rank applicants. Therefore, it is very important to submit a complete application and respond quickly to
requests for information. When notified that GR benefits are approved, the applicant must provide a
copy of this application and the approval letter to the ALH for their records and service plan.
ak-dsm-ss2/
General Relief staff can be reached at 907-269-3666 or 800-478-9996 to answer questions about the application.
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Where has the Applicant lived in the past 12 months? (Check all that apply)
Own Home/With Family
Homeless, not in a shelter
Rented Apartment/Home
Jail/Prison
Group Home
Psychiatric Facility
Assisted Living Home
Crisis Stabilization Unit
Skilled Nursing Facility
Residential Treatment
Shelter
Boarding Home
Referrer Contact Information
If someone other than the applicant is assisting with the application, complete this section.
Title: ________ First Name: ________________ Last Name: _________________ Suffix:
Relationship to Applicant: ____________________________________
Agency Name: ________________________________________Provider ID: _______________
Mailing Address___________________________________________________ Suite/Apt.:
City: __________________________ State: ________ Zip Code: _____________
Phone work: _____________________ Phone cell: ____________________ Other:
Fax: ___________________ DSM: _________________________________________________
Applicant Demographic Information
First Name: _________________ Middle Initial: ____Last Name: ______________ Suffix: _____
Mailing Address___________________________________________________ Suite/Apt.:____
City: __________________________ State: ________ Zip Code: __________
Physical Address: ________________________________________City: ____________________
Current Location Type: (hospital/my home/friend’s house/etc.)
Phone home: _____________________Phone cell: Phone work:
DOB: _____________ Gender: _________________ Marital Status: ______________________
Primary Language: Second Language:
Ethnicity: ___________________________Tribe (if any): ______________________________
Health Insurance/Benefits (list all that apply Ex. IHS, VA, Medicaid):
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Describe why the need for Assisted Living Home (ALH) continues
Describe what independent living, supportive housing or in-home services have already been tried
Describe the services and supervision needed
Expected duration and goals of placement
Application Narrative
Applicant First Name Applicant Last Name
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INCOME
Source of Income
Name of Income Source
Estimated Monthly
Amount
Comments
Social Security/SSDI
Supplemental Security
Income (SSI)
Public Assistance
Veteran’s Benefits
Senior Benefits
Native Dividends
Other
(Dividends/Interest)
Pension
Other Income
Other Income
Other Income
Total
RESOURCES
Resource
Name of Bank
Resource Details
Estimated Value
Comments
Checking Account
Balance
Savings Account Balance
Burial Fund
Second Home
Land (non-tribal)
Second Vehicle
RV
4-wheelers/motorcycles
Stocks, Bonds,
Investments
Whole Life Insurance
Expected settlement
windfall or back pay
Other Resource
Total
Income and Resources Worksheets
Not all income and resources are counted toward eligibility, but must be disclosed. Please enter $0 and note
N/A in comments if this income or resource type does not apply, 7 AAC 47.340 through 7 AAC 47.355. If an
applicant is approved for General Relief benefits and income or resources are later discovered that can be
applied to the cost of care, the Department will recalculate the client cost of care for any month that income or
resource was available to them and retroactively bill the resident for the additional amount owed. If income or
resources are discovered to be available to the resident on an ongoing basis above the allowed amounts, the
client may no longer be eligible for the General Relief Program.
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Functional Assistance Required
Activity of Daily
Living
Frequency of Assistance
Extent of Assistance
Independent
Occasional
Often
Always
Minimum
Moderate
Maximum
Bathing
Dressing
Grooming
Toileting
Eating
Transferring
Physician’s Report
The Physician’s Report must be completed and signed by a physician, physician’s assistant or advanced
nurse practitioner. Attach additional information as needed.
Applicant Information
Medication Prescribed
Dosage
Condition Medication
Prescribed to treat
Instructions/Comments
Applicant requires the following assistance with medication, (check all that apply)
Assistive Devices, Technology, Equipment or Special Diet Used
Impairment
No
Yes
If Yes, give description
Hearing impaired?
Vision impaired?
Mobility impaired?
Special Diet needed?
Medical Equipment
or devices used?
Applicant First Name Applicant Last Name
Date of Birth: Height: Weight:
Medical History and Current Medical Problems
Primary Diagnosis (please add ICD-10 code):
Secondary Diagnosis (please add ICD-10 code):
Chronic Conditions (include behavioral health):
No Assistance Reading Label Reminder to take
Supervision Administration of Meds
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Safety
Condition
No
Yes
If Yes, Describe
Allergies?
Disoriented?
Memory Problems?
Using drugs or alcohol?
At risk of causing harm to
self or others?
Please describe any additional information of significance
Recommendation for Care
Date:
Physician/PA/ANP Signature
Printed Name:
Phone #: Fax #: License #:
Mailing Address/city/state/zip:
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General Relief Contract
Applicant First Name Applicant Last Name
Applicant/ Legal Decision Maker initial each item and sign below
________ I am applying for the General Relief (GR) Assisted Living Home Care Benefit because I need
Assisted Living Home Care and have no other way to pay for this service.
________ A waitlist to receive benefits may be in effect, depending on authorized funding and the number of
people using the program.
________If I am on the waitlist for benefits and my name is pulled off of the waitlist to receive benefits, the
General Relief Program will attempt to contact me, any named legal decision maker, the person who helped me
fill out the application for GR, and the two additional people listed on the General Relief Application to notify
me of my approval to begin receiving benefits. If the GR Program does not hear back from me, my legal
decision maker, service provider or named contacts within 20 days, my application will be closed.
________The General Relief benefit can be used at any Assisted Living Home that has a current provider
agreement with the SDS General Relief program. The General Relief program cannot pay a home that is not
licensed and a current SDS General Relief provider and cannot back date a provider agreement.
________If I move in to an Assisted Living Home before I am approved for General Relief benefits, I am
responsible for full payment to the home up to the date I am approved for benefits. General Relief does not
back-date the approval date.
________It is my responsibility to find an Assisted Living Home that can meet my care needs. An Assisted
Living Home has the choice to enter into a contract or not with me based on the ability to care for my needs and
the existing responsibility to care for other residents in the Assisted Living Home.
________I am responsible to make payment of my client share of the daily rate to the contracted Assisted
Living Home. The General Relief program will create a Calculation Sheet that shows how much I pay and how
much the State of Alaska pays. If my income or resources change, I must contact General Relief to make
adjustments to how much I pay.
______The money that is paid by the State of Alaska to cover my cost of care will be reimbursed by me when
retroactive and other sources of eligible income or resources become available to me. This amount will not be
more than the amount the State has paid for my cost of care. This money will be paid to the “Division of Senior
and Disabilities Services” and remitted to the General Relief Program. Call 269-3666 to find out amount.
______If approved, benefits will last 1-6 months dependent on need. If benefits are still needed after that time
period, I must complete a renewal packet and turn it in to the GR program 15 days prior to the benefit ending
date on my approval letter or benefits will be terminated.
______If I terminate my General Relief benefits or allow my benefits to lapse, I will have to reapply to
receive benefits again and may be placed on a wait list if one is in effect.
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______The funding source is State of Alaska General Funds. The availability of this program is based on
annual legislative appropriations. There is a chance each fiscal year that this program could be discontinued.
______The General Relief Program only provides payment assistance for Assisted Living Home Services as
described on the front of this packet. It does not provide case management or monitoring of the care provided.
_____If I am being abused, neglected or exploited by anyone, including ALH staff, or I feel that I cannot
manage my own care contracts, benefits, or bills, I should report this to Central Intake right away by calling
269-3666. I cannot be evicted for reporting.
______To file a complaint about the quality of care, environment or services provided by my ALH, I can call
the Long Term Care Ombudsman’s Office at 334-4480 or Central Intake at 269-3666. I cannot be evicted for
filing a complaint.
Applicant First Name Applicant Last Name
Applicant Signature Date
Legal Decision Maker (LDM) First Name LDM Last Name
LDM Signature Date
Type of Legal Decision Maker:
Guardian Conservator Power of Attorney
Other:
** Note: Attach proof of Guardianship/Conservator/POA status
SIGNATURES
By signing below, I certify that the information included in this Application is true and accurate to the best of
my knowledge. Misrepresentation or providing false information may be criminally prosecuted as an unsworn
falsification under AS 11.56.210
Signature of Applicant Date
Signature of Referrer Contact from page 3 (if applicable) Date
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