E: Aged and Disabled Waiver Assisted Living Services Client Consent for Multiple Occupancy (MILTC-21)

Appendix E
Preprinted DSS-5N

Client Name __________________ Address__________________

Social Security Number _____________ __________________

I, __________________________desire to share an assisted living

unit with _______________________________________
(name/relationship).

I understand this is a voluntary choice. I may request to change this living
arrangement at any time and will notify the facility administrator and my
Services Coordinator of this decision.

Multiple occupancy rates are computed at 80% of the single occupancy
rate. Multiple occupancy requires prior approval of DHHS and consent
form signed by the client and roommate. I have read and understand
the consent as stated above and agree to comply with the terms

______________________________________________________
Client/Guardian Date
______________________________________________________
Roommate/Guardian Date

MILTC-21 Rev. 10/98 (57091)
(No previous version)