Client Intake and Alignment Portal Complete the HCS/CLASS intake profile to establish the compliant state records required for billing authorization. Section 1: Individual Data & Demographics (HHS Form 8665-ID) Client Full Name: Medicaid TPI ID: Date of Birth: Social Security Number (SSN): Gender: Female Male Other Marital Status: Single Married Divorced Widowed Separated Language Preference: English Spanish Other Race / Ethnicity: White Black / African American Hispanic / Latino Asian American Indian / Alaska Native Other Level of Need (LON): LON 1 (Standard) LON 5 (Standard) LON 6 (Enhanced 1:1) LON 8 (Standard) LON 9 (Enhanced 2:1) Living Arrangement: Host Home / Companion Care With Family / LAR Alone (Independent) Group Home (3-4 Bed) Housing Assistance Status: No Assistance Receiving Housing Assistance Communication Needs: Verbal (Speech) Non-verbal Sign Language Communication Device / AAC Section 2: HCS Program Contact Information (HHS Form 8583) Legally Authorized Representative (LAR) LAR Full Name: LAR Relationship: LAR Address: LAR Phone Number: LAR Email Address: Primary Caregiver / Host Home Provider Caregiver Full Name: Caregiver Address: Caregiver Phone Number: Caregiver Email Address: LIDDA Service Coordinator (SC) Service Coordinator Name: LIDDA Agency Name: SC Phone Number: SC Email Address: Backup / Emergency Contact Backup Contact Name: Backup Relationship: Backup Address: Backup Phone Number: Backup Email Address:
