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 |
|
|