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Fill Out Your Rem Iowa Service Application Form

The REM Iowa Service Application form is a crucial document used to apply for community services for individuals with intellectual disabilities, developmental disabilities, or mental health needs. This form gathers essential information about the applicant and their circumstances, ensuring they receive the appropriate support and resources. Interested in applying? Fill out the form by clicking the button below.

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Article Structure

The REM Iowa Service Application form is a crucial tool designed to streamline the process of applying for community services for individuals with intellectual disabilities, developmental delays, and mental health needs. It gathers a range of important information, beginning with how applicants learned about REM Iowa services, whether through family, friends, or healthcare providers. The form then prompts for essential personal details, including the applicant's full name, current address, and a brief medical history, particularly focusing on diagnoses that might influence care. It addresses legal guardianship, offering a space to identify any guardians, and captures the financial responsibility details through case manager information. Applicants must specify the types of services desired, such as residential programs or day habilitation, and document any past service experiences. Additionally, the form explores critical behavioral and medical histories, supporting the agency in deciding the most suitable care options. Finally, the application reassures applicants by clarifying that all information provided will be used solely for service administration purposes, making it clear that privacy and confidentiality are paramount. By thoughtfully filling out this form, individuals take an important step toward accessing the support they need.

Rem Iowa Service Application Example

REM IOWA COMMUNITY SERVICES & REM IOWA DEVELOPMENTAL SERVICES

SERVICE APPLICATION FORM FOR ID/DD/MH SERVICES

Date of Application:

REFERRAL TO REM IOWA

How did you become aware of REM Iowa services?

Family | Friend

REM Iowa website

The MENTOR Network website

Hospital

REM Employee

Other Provider

Case Manager | Care Coordinator

Other

If other, please document from whom/where:

APPLICANT INFORMATION

Applicant’s Full Name:

When Desired:

Placement in Jeopardy

Next Available

Within six months

Within one year

If placement in jeopardy, indicate the date of discharge:

Current Address:

Telephone Number:

Birth Date:

Gender:

Male

Female

Height:

Weight:

lbs.

Primary Diagnosis:

Intellectual Disability

Mental Health/Illness

Autism Spectrum:

Yes

Personality Disorder:

Yes

Schizophrenia or Schizoaffective Disorder:

Yes

Other Diagnosis:

LEGAL GUARDIANSHIP STATUS

Does this applicant have a guardian?

Yes

Name of Guardian:

Relationship:

FINANCIAL RESPONSIBILITY

Case Manager | Care Coordinator Name:

Telephone Number:

Email:

IME Determination Date:

Level of

Care:

SERVICE(S) DESIRED

Type of Services Desired:

ICF/ID

24-hour Waiver (Adult)

24-hour Habilitation

Host Home**

Communities desired:

Day Habilitation (*indicates available communities below)

Unknown

1. Children ICF/DD (ID must be primary diagnosis):

Council Bluffs Only

Adult ICF/DD (ID must be primary diagnosis):

1st Opening

Shelby

Washington

Coralville

Cedar Rapids | Marion | Hiawatha

No preference

Waiver Services:

1st Opening

Des Moines Area*

Mt. Pleasant

Atlantic

Ft. Madison

Mt. Vernon

Avoca

Harlan

Shelby

Cedar Rapids |Marion| Hiawatha*

Iowa City|Coralville*

Tipton

Clinton

Keokuk

Vinton*

Council Bluffs

Marshalltown*

Waterloo | Cedar Falls |Waverly

Davenport | Bettendorf

Mason City

No Preference

Other community (s):

**Host Home is a service where individuals live in private family homes and receive specialized assistance from a dedicated caregiver we call a Mentor.

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Revised 03.17

HISTORY OF SERVICES

Residential/ in-home services (e.g. hourly services, 24-hour waiver, ICF/ID, nursing home, etc.)

Has the applicant always lived at home?	Yes	No

Service	Provider

Dates

Day/Vocational Services
Has the applicant ever been employed:	Yes	No	At a day program?	Yes	No

Service

Provider

Dates

REFERRAL HISTORY

Has the applicant ever been arrested?

Yes

If yes, provide: Date(s):

Reason(s):

Outcomes:

Does the applicant have a current court committal?	Yes	No
Has the applicant been accused/convicted of sexual abuse?			Yes	No
If yes, provide: Date(s):
Outcomes:
Has the applicant had any history of cruelty to animals?			Yes	No
If yes, provide: Date(s):
Outcomes:
Has the applicant attempted suicide or had suicidal ideations?			Yes	No
If yes, provide: Date(s):
Outcomes:
Has the applicant had any history of fire setting?			Yes	No
If yes, provide: Date(s):
Outcomes:
Has the applicant had any history of cutting self, swallowing or insertion of foreign objects or			Yes	No
strangulation?
If yes, provide: Date(s):
Outcomes:
Has the applicant had physical aggression that required physical, mechanical or chemical restraint
via injection over the past 12 months?			Yes	No

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Revised 03.17

FAMILY INFORMATION

Mother’s Name (first & last):

Address:

Home Telephone #:

Work Telephone #:

Email Address:

Father’s Name (first & last):

Address:

Home Telephone #:

Work Telephone #:

Email Address:

Sibling’s Full Name(s) (first & last):

Significant Other Name (first & last):

Address:

Home Telephone #:

Work Telephone #:

Email Address:

APPLICANT’S FINANCIAL INFORMATION

Receive Financial Assistance:

Yes

If yes, type:

SS (Social Security)

SSI (Supplemental Social Insurance)

If other, document type:

VA (Veteran’s Benefits)

Child Support

Adoption Subsidy

Other

Does applicant have Title 19?

Yes

Managed Care Organization (MCO)?

Amerihealth Caritas

Amerigroup

United Health

Optum N/A

Does applicant have Waiver funding?

Yes

Does applicant have Habilitation funding?

Yes

Does applicant have private insurance?

Yes

Does applicant have other income (trust fund, etc.)?

Yes

APPLICANT’S HEALTH/MEDICAL INFORMATION

Current Medication(s) or can attach current medication orders or record:

Name	Dose	Frequency	Reason for Taking

Prescribed By

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Revised 03.17

Physical disabilities that require the use of adaptations (e.g. AFOs {braces}, orthopedic shoes, cane, walker, wheelchair,

etc.)	Yes	No
If yes, list adaptive equipment:
Seizures:	Yes	No	History of
If yes or history of, describe type and frequency:
Vision Problems:		No	Yes – correctable with glasses		Yes – but chooses not to wear glasses
		Yes - uncorrected		Blind Comments:
Hearing Problems:		No	Yes – correctable with hearing aides		Yes – but chooses not to wear hearing aides
		Adapt by others speaking louder			Deaf

Comments:

Skill Checklist: (please check items which best describe applicant)

BEHAVIOR	Consistently Sometimes Never Comments
Becomes upset when
redirected/corrected
Demands excessive
attention from others
Complains of being
persecuted
Pretends to be ill
Changes mood without reason
Bosses or manipulates others
Hyperactive
Hoards things
PICA (eats inedible objects) (if
displays, list items in
comments)
Self stimulation
Self injurious behavior
Verbally aggressive
Physically aggressive toward
others
Physcially aggressive toward
objects
Displays sexually inapprorpriate
behavior
Removes clothing in public
Tears clothing
Steals other's belongings
Elopes / runs away from home
Uses tobacco
Uses alcohol
Uses other drugs

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Revised 03.17

LEISURE ACTIVITIES

Interests:

Hobbies:

Dislikes:

CLOSING

The information we have asked you to provide is necessary for the effective administration of the services for which you are applying. The information collected will only be used by authorized agency personnel. Use of this information for purposes other than expressed herein will not occur without your prior written approval, unless such other use is specifically authorized by law.

Attach any of the following materials that may be helpful in determining eligibility for service:

Most recent psychological evaluation

Most recent education and/or vocational report

Most recent progress reports or plan of care

Physical and/or specialty medical examinations

Other Documentation that you feel would be helpful


Completed by:
Applicant Name:					Date:
Case Manager Name:					Date:
Parent/Guardian Name:					Date:
Name/Title:					Date:

Please return form to: REM Iowa (please check website for current contact information @ www.remiowa.com)

or send to REMIowaReferral@thementornetwork.com

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Revised 03.17

Get Rem Iowa Service Application PDF Form

Form Characteristics

Fact Name	Details
Purpose of the Form	The REM Iowa Service Application form is designed for individuals seeking ID/DD/MH services.
Application Date	Applicants must provide the date of their application on the form.
Referral Sources	Individuals can indicate how they became aware of REM Iowa services, including family, friends, or advertisements.
Legal Guardianship Status	The form collects information regarding the applicant's guardian status, including the name and relationship of the guardian.
Financial Information	Applicants must disclose their financial assistance status, including types like Social Security or Veterans Benefits.
Governing Laws	This application is subject to the laws governing mental health and disability services in Iowa.

Guidelines on Utilizing Rem Iowa Service Application

Once the Rem Iowa Service Application form has been filled out, it must be submitted to the appropriate REM Iowa contact address indicated at the bottom of the form. Regulatory personnel will review the information provided to determine eligibility for services. Ensure all sections are completed accurately to prevent any delays in processing.

Enter the Date of Application at the top of the form.
Indicate how you became aware of REM Iowa services by checking the suitable box.
Fill out the Applicant Information, including the applicant’s full name, desired placement date, current address, phone number, birth date, gender, height, weight, and primary diagnosis.
If applicable, provide the details about Legal Guardianship Status, including if there is a guardian and their relationship to the applicant.
Input the Financial Responsibility details—this includes the case manager or care coordinator’s name, contact information, IME determination date, and level of care.
Select the Type of Services Desired by checking the appropriate boxes for ICF/ID, 24-hour Waiver, 24-hour Habilitation, Host Home, and any other communities desired.
Outline the applicant’s History of Services by responding to questions about residential/in-home services, employment history, and any previous day or vocational services.
Answer the Referral History questions, including any history of arrests, court commitments, accusations or convictions, and behaviors such as self-harm or aggression.
Provide Family Information, listing the mother’s and father’s names, addresses, telephone numbers, and email addresses, along with significant others and siblings.
Detail the applicant’s Financial Information, indicating if they receive any financial assistance or have Title 19, Waiver funding, or private insurance.
Document the Health/Medical Information, including current medications, physical disabilities, and any relevant medical history.
Complete the Skill Checklist by checking items that describe the applicant's behavior.
List the applicant's Leisure Activities, including interests, hobbies, and dislikes.
Fill out the Closing section with your name and date, along with the case manager and parent/guardian names and dates.
Attach any supporting documents such as psychological evaluations or medical reports if available.
Return the completed form to the address specified on the form or send it via email to the designated REM Iowa contact.

What You Should Know About This Form

What is the REM Iowa Service Application form?

The REM Iowa Service Application form is a document used to apply for services related to intellectual disabilities, developmental disabilities, or mental health needs. It collects essential information about the applicant, including personal details, desired services, medical history, and any existing guardianship status.

How do I submit the REM Iowa Service Application form?

You can submit the completed application form either via email or by mail. To email, send the document to REMIowaReferral@thementornetwork.com. Alternatively, you can mail it to the appropriate address listed on the REM Iowa website. Ensure that all required information is accurately filled in to avoid delays in processing.

What information do I need to provide in the application?

The application requires detailed information including the applicant's full name, contact information, birth date, gender, primary diagnosis, financial responsibility details, and any relevant medical history. Additionally, indicate the type of services desired and any past service history. This comprehensive data helps to assess the needs of the applicant effectively.

What if the applicant has specific medical conditions?

If the applicant has specific medical conditions or requires adaptive equipment, this information must be included in the medical history section of the form. Clearly stating any prescriptions, disabilities, or other health issues helps REM Iowa tailor their services to meet individual needs.

Is there a fee to apply for services?

No, there is typically no fee for submitting the REM Iowa Service Application form. However, if the applicant is eligible for specific services, those services may have associated costs that vary based on funding sources and insurance coverage.

How long does it take to process the application?

The timeline for processing the application can vary. Once the application is submitted, it will be reviewed by REM Iowa’s staff, who will follow up if additional information is needed. Therefore, it is crucial to submit a complete form to avoid delays. Generally, you may expect to hear back in a few weeks.

What should I do if I need assistance while completing the form?

If you require help while filling out the application, do not hesitate to reach out to a case manager, caregiver, or support person. They can provide guidance and assist you in understanding any aspects of the form that are unclear. Additionally, REM Iowa staff are available to answer questions regarding the application process.

Can I apply for services for someone else?

Yes, you can apply on behalf of someone else, provided you have their consent and authority to do so, especially if you are their legal guardian or have power of attorney. Make sure to include your relationship to the applicant in the application to clarify your role in the process.

Common mistakes

Filling out the REM Iowa Service Application form can be straightforward, but mistakes can lead to delays or complications in the application process. One common error is failing to provide complete applicant information. Including all requested details, such as the applicant’s full name, complete address, and date of birth, is essential. Omissions in this section can result in confusion and hinder progress.

Another frequent mistake is an incomplete understanding of the desired services. Applicants might choose services without clearly indicating their priorities or preferences. This can lead to placement in less suitable environments or services that do not meet the applicant's needs. It is crucial to review service options thoroughly and mark all relevant boxes accurately.

Inaccuracies in the financial information section are also problematic. Many applicants underestimate the importance of providing correct and detailed information regarding income, insurance, and funding sources. Errors here can affect eligibility and the ability to access required services. Applicants should ensure that all financial details are current and precise.

Participants occasionally neglect to update referral history. This part of the form is vital for understanding the applicant's background and current needs. Failing to disclose a history of arrests, court commitments, or previous service experiences can lead to misunderstandings about the applicant's situation.

Moreover, applicants sometimes overlook the inclusion of necessary medical information. Omitting current medications, disabilities, or health concerns could result in inadequate support or inappropriate services being offered. All health-related details should be documented carefully to provide a comprehensive view of the applicant's needs.

Documentation accompanying the application is often disregarded. Applicants might forget to attach relevant reports, such as psychological evaluations or medical records. Providing this information is crucial for establishing eligibility and understanding the applicant's requirements.

Another mistake involves unclear descriptions in the skill checklist section. Not providing specific comments about behavior or skills can lead to misinterpretations of the applicant's capabilities. Clear and descriptive feedback is necessary for the review team to make informed decisions about services.

Finally, an overlooked checklist can lead to an application being returned or delayed. Applicants should double-check all parts of the form to ensure that every question has been answered and all required signatures are included. A thorough review helps prevent unnecessary setbacks and ensures a smooth application process.

Documents used along the form

The REM Iowa Service Application form is crucial when applying for community services. However, several other forms and documents may often accompany it to ensure a complete application process. Below is a list of these documents, each serving a specific purpose.

Authorization for Release of Information: This document permits REM Iowa to share your health information with relevant third parties. It helps streamline the communication process among your healthcare providers, ensuring everyone has the necessary information.
Intake Assessment Form: An intake assessment gathers detailed information about the applicant's needs and history. It aids case managers in understanding the applicant’s unique situation and requirements.
Psychological Evaluation Record: This record provides insight into the applicant's mental and emotional health. It can assist in determining appropriate services and support needed.
Medical History Form: This form outlines the applicant’s past and present medical conditions. It ensures that relevant medical information is available for assessing service eligibility.
Financial Disclosure Statement: This document details the applicant's financial situation. It helps determine eligibility for various funding programs and services.
Behavioral Assessment Form: This form analyzes behavioral patterns and needs. It helps the service provider create a tailored support plan for the applicant.
Individualized Service Plan (ISP): The ISP sets forth the specific services that will be provided to the applicant. It outlines goals, objectives, and strategies for support.
Guardian Authorization Form: If the applicant has a legal guardian, this form designates the guardian’s authority to make decisions regarding the applicant’s services and care.
Referral Letter: A referral letter from a healthcare provider or case manager can provide additional context to the applicant’s needs. It often supports the application by highlighting necessary services.

Providing these additional forms can significantly improve the application experience and ensure that the applicant receives the appropriate support. Take the time to gather everything needed to create a comprehensive application package.

Similar forms

Iowa Medicaid Application: This document collects personal and financial information to determine eligibility for Medicaid services, similar to the information required in the Rem Iowa Service Application form.
Social Security Benefits Application: Here, individuals provide personal history and financial details to qualify for Social Security benefits, paralleling the guidelines in the Rem Iowa Service Application.
Department of Human Services Service Application: This application requires information about one's needs and circumstances to access state services, like the details needed on the Rem Iowa form.
Medicare Application: Applicants need to submit health, financial, and personal information to register for Medicare, mirroring the detailed requests in the Rem Iowa Service Application.
Child ISP (Individualized Service Plan): This document outlines the support and resources for children with developmental needs, requiring similar personal and medical information as seen in the Rem Iowa Service Application.
Assistance for Persons with Disabilities Application: This form also gathers personal, financial, and medical data to assist individuals with disabilities, resonating with the comprehensive nature of the Rem Iowa Service Application.

Dos and Don'ts

When filling out the Rem Iowa Service Application form, two essential lists can help you navigate the process successfully. Here are four key things you should and shouldn't do:

Do ensure all information is accurate and up-to-date.
Do attach any necessary documentation that supports your application.
Do follow the instructions provided carefully.
Do ask for assistance if you find any part of the form confusing.

Don't leave any required fields blank; this can delay your application.
Don't provide misleading or false information.
Don't rush through the application; take your time to ensure thoroughness.
Don't forget to check your contact information for any errors before submission.

Misconceptions

There are several misconceptions regarding the Rem Iowa Service Application form that could lead to confusion among applicants and their families. Below is a list of these misconceptions along with explanations to clarify them.

It is only for individuals with intellectual disabilities. This form also accommodates individuals with mental health issues, autism spectrum disorders, and various other diagnoses. The application is inclusive of diverse needs.
All information provided is public. The information gathered through the application is confidential and used solely for evaluating eligibility for services. Authorized personnel will handle it securely.
The application needs to be completed by the applicant. While the applicant should provide personal details, caregivers, parents, or guardians can assist in filling out the form. Team involvement is welcome and often necessary.
Submitting the application guarantees service approval. Completing the application does not automatically ensure that services will be granted. A review process will determine eligibility based on available resources and specific needs.
Only family members can submit the application. Any authorized individual, including case managers or service coordinators, can assist with submitting the application. This encourages teamwork in securing services.
All required fields must be filled out perfectly. While complete and accurate information is ideal, minor errors can often be corrected through follow-up communication. Accuracy will help streamline the review process.
There are no community options available beyond the form. The application outlines potential services and communities, but applicants may discuss additional preferences or needs directly with REM Iowa staff during the assessment process.
It is a lengthy and complicated process. While there are several components to the application, taking it step by step can make it manageable. Additionally, assistance is available from case managers and support staff to clarify any part of the process.

Understanding these misconceptions can help applicants and their families navigate the Rem Iowa Service Application process more effectively.

Key takeaways

Filling out the Rem Iowa Service Application form is a crucial step in accessing necessary services for individuals with specific needs. Below are key takeaways to help you through the process:

Provide Accurate Information: Ensure that all details about the applicant, including personal, medical, and financial information, are filled in accurately. This includes specifics such as the primary diagnosis and current medications.
Understand Service Options: Familiarize yourself with the types of services available, such as ICF/ID, waiver programs, and host home options. Knowing what is offered can guide your selections on the form.
Gather Supporting Documents: Attach any relevant documents that might aid in determining eligibility for services. These include psychological evaluations, medical reports, or any other important paperwork.
Consult with Case Managers: If applicable, ensure that communication is open with case managers or care coordinators. Their guidance can provide clarity on several aspects of the application process.

These steps are essential to ensure that the application process goes smoothly. Taking the time to complete the form thoughtfully can lead to timely access to the services needed.

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