LTCRR Intake Form

Printer-friendly version

Long-Term Care Resident Rights Intake Form

If you have Apple Health (Medicaid) benefits and live in an Assisted Living Facility (ALF), Adult Family Home (AFH), or Enhanced Services Facility (ESF) and received a notice of transfer or discharge, you may be eligible for services through DRW’s Long Term Care Residents Rights Program. Please call us at (888) 437-0017 Monday through Friday from 9:00 a.m. – 12:00 p.m. and 1:00 p.m. – 4:00 p.m. to be screened for an appointment with an advocate. Alternatively, please fill out the form below and DRW will call you back to conduct an intake screening and set up an appointment. Language interpreters are available via LanguageLine Solutions. Please use 711 for Washington Relay Service.

Resident Name(Required)
Do you receive Apple Health (Medicaid) Benefits?(Required)
Did you receive a notice of transfer or discharge from your facility?(Required)
Were you recently removed from your long term care facility without notice?(Required)
Do you need an accommodation for your intake appointment?(Required)
This field is for validation purposes and should be left unchanged.