The facility will indicate by placing an “X” in the “Available” column if the payment option is accepted (may check more than one). Please indicate in the “Comments” column below if a pre-determined length of private funds payment source is required before acceptance of Medicaid or waivered service funds; and if yes, indicate the number of months required.

Payment Options for Housing Contract

Payment Option Accepted Comments
Private Pay
Sliding Scale
Housing Support (formerly Minnesota Group Residential Housing) Payments
Federal Rent Subsidy
Federal Rent Subsidy
Other; explain

Payment Options for Services

Payment Option Accepted Comments
Waivered Services (EW, CADI, BI); specify any limitations
Private Pay
Long Term Care Insurance
Others;explain