Please read the following information concerning this Intake Form and Complaint/Grievance Procedure:
We are asking you to complete the client intake form to the best of your knowledge so we understand how you would like to receive services. Some basic information (*) is needed to meet compliance with federal and state reporting requirements and to target consumers age 60 and older who have the greatest economic and social need, such as individuals who are low-income minority, frail, and rural. Requests for services are processed as funds allow.
Your income level is not used to qualify you to receive services, but rather as a means to gather demographic data to various entities to show the need for continued funding of services. Nobody will contact you unless you choose so in order to receive information about services which might be available to you.
The purpose of the Complaint/Grievance/Appeal Procedure is
· To ensure fair and equitable treatment of all consumers, eliminate dissatisfaction, resolve problems and
· To establish complaint and appeals procedures that inform the consumers of their rights to complain and receive a written response at the provider level
Any OAA/OCA (Older Americans Act/Older Coloradans Act) eligible consumer who has a complaint/grievance with the organization asking you to fill out this assessment form has the right to file a complaint/grievance with said organization and, if not satisfied with the organization’s decision, to appeal that decision with either the local AAA (Area Agency on Aging) or the SUA (State Unit on Aging).
The complete Complaint/Grievance/Appeal Procedure is available upon request by contacting your local AAA and/or the SUA as follows:
Office of Community Access and Independence
Aging and Adult Services
1575 Sherman Street, 10th Floor
Denver, CO 80203
(303) 866-2800 (Main Line)
(303) 866- 2977 (Fax)
(888) 866-4243 (Toll Free)
Any person receiving services shall have the opportunity to contribute towards the cost of the service. No eligible person shall be denied a service because of their inability and/or choice not to contribute.
While we ask you to make an honest effort to gather this basic information, we cannot deny services to clients on the basis of them refusing to provide the requested information, as our programs are not means tested. Since our programs are specifically for the elderly, particularly for persons age 60 or over, the date of birth needs to be filled in. If the client refuses to provide his/her date of birth, please enter January 1 and the year which would make them the age they are stating. Then, indicate in the notes of the consumer detail record that the date of birth is not factual, as the client would not provide it.
This form may be used for the following services (any other services require one of the available assessment forms, rather than just a basic intake):
· Assisted Transportation or Assisted Transportation (State)
· Counseling or Counseling (State)
· Education or Education (State), if the client is registered
· Evidence-based Disease Prevention or Health Promotion or Evidence-based Disease Prevention and Health Promotion (State)
· Information and Assistance or Information or Assistance (State), if the client is registered
· Material Aid or Material Aid (State)
· Nutrition Education or Nutrition Education (State), if the client is registered
· Outreach or Outreach (State), if the client is registered
· Public Information or Public Information (State), if the client is registered
· Reassurance or Reassurance (State)
· Transportation or Transportation (State)
If you have any questions, please contact your local AAA office.