How to Request and Complete the Florida 701S Screening Form

Florida’s 701S screening form is a phone questionnaire administered by an Aging and Disability Resource Center (ADRC) to determine whether a senior or adult with a disability qualifies for long-term care services and where they land on the state’s waitlist. To request one, call the Florida Elder Helpline at 1-800-963-5337 or contact your local ADRC directly.¹ A certified screener walks you through health, financial, and living-situation questions, enters your answers into the state’s tracking system, and the system generates a priority score. That score places you on the Assessed Priority Consumer List (APCL) for the Statewide Medicaid Managed Care Long-Term Care program and other Department of Elder Affairs-funded programs.²

Who Qualifies to Be Screened

Two groups of Florida residents can request the screening: adults aged 65 and older, and adults aged 18 through 64 who have a physical disability, brain injury, HIV/AIDS, or are medically fragile.³ The form is aimed at people who need help with daily activities and want to stay at home or in a community setting rather than move into a nursing facility. The person requesting services, or an authorized representative acting for them, must participate in the screening, and it must be completed in full before anyone is placed on the waitlist.⁴

How to Request the Screening

Call the Elder Helpline at 1-800-963-5337 to be routed to your local ADRC, or look up your area’s center on the Department of Elder Affairs website.¹ The screening is conducted by phone by ADRC staff certified by the Department of Elder Affairs.⁴ There is no fee. If the applicant cannot participate personally, an authorized representative with legal authority to act on their behalf in Medicaid-related matters can speak in their place.

What to Have Ready Before the Call

The screening covers a lot in one call, and having documents within reach prevents callbacks and delays. Pull the following together first.

The applicant’s Social Security number. Federal regulation requires each person seeking Medicaid to furnish an SSN as a condition of eligibility, collected under 42 CFR 435.910 for screening and referral purposes. If the applicant has no SSN or cannot recall it, the ADRC must help them apply for one, and services cannot be denied or delayed while the Social Security Administration processes the request.⁵
Date of birth, current Medicaid number if any, and basic demographics. The form records sex, race, ethnicity, primary language, English proficiency, and marital status.
Living arrangements: who lives in the home, the type of residence, whether a primary caregiver is present, and any recent stay in a nursing or rehabilitation facility.
Monthly income and asset totals for the applicant and, if married, the couple. Recent bank statements and Social Security or pension award letters help.
Caregiver contact information. The statute requires the Department to request alternate contact names and phone numbers, so have a name and number for the primary caregiver or authorized representative.⁴
A summary of medical conditions and diagnoses. Medical records aren’t strictly required for the phone call, but having the details in front of you helps the screener record health conditions and cognitive impairments accurately.

Check biographical details against an official ID or Social Security card before the call. One transposed digit in an SSN or date of birth can hold up case creation in the state’s tracking system.

What the Screener Asks

The 701S form moves through several sections in order, and every answer feeds the priority score. Knowing the layout in advance makes the call go faster.

Health Status and Medical Conditions

You’ll be asked to rate the applicant’s current health and compare it to a year ago. A checklist covers past and current conditions such as arthritis, diabetes, heart problems, and incontinence. The screener also asks whether the applicant has access to medical care and transportation to appointments, and whether cost or lack of insurance limits that access. Memory problems and cognitive impairments like Alzheimer’s disease are documented here.

Activities of Daily Living

This section measures how much help the applicant needs with basic self-care: bathing, dressing, toileting, transferring in and out of a bed or chair, and eating. For each activity the screener records two things: the level of assistance the person needs, and how much help they actually receive. A gap between need and what’s received pushes the priority score up.

Instrumental Activities of Daily Living

These are the more complex tasks of independent living: preparing meals, managing medications, handling money, doing housework, and using transportation. The same need-versus-received framework applies. Trouble managing medications often signals a safety risk that raises urgency.

Therapies and Specialty Care

A frequency checklist covers treatments such as dialysis, insulin assistance, catheter care, oxygen use, wound care, physical therapy, and skilled nursing. If the applicant currently receives any of these, the screener notes how often.

Caregiver Assessment

If a caregiver is involved, the screener asks about that person’s mental and emotional strain, physical health, and confidence in continuing to provide care. A caregiver in crisis or one who is about to stop pushes the applicant’s situation toward higher urgency.

Nutrition

The last section covers meal frequency, whether the applicant eats alone, daily fruit and vegetable intake, weight changes, special diets, chewing or swallowing difficulty, and alcohol use. It also asks about SNAP participation and any unmet food needs.

How the Score and Waitlist Placement Work

Once the sections are complete, the state’s tracking system generates a priority score.⁶ A higher score reflects a greater risk of nursing home placement without community services. Scores group into ranks:

Rank 1, score 0–15: low priority.
Rank 2, score 16–29: low priority.
Rank 3, score 30–39: high priority.
Rank 4, score 40–45: high priority.
Rank 5, score 46 or above: high priority.
Rank 6: Aging Out referral, for individuals transitioning out of another program.
Rank 7: imminent risk of nursing home placement.
Rank 8: Adult Protective Services high-risk referral.

Ranks 6 through 8 are assigned by referral circumstances, not the numerical score. Someone referred by Adult Protective Services as high-risk goes to Rank 8 regardless of their screening answers.⁶

After the screening, the Department of Elder Affairs notifies the applicant or their representative that they have been placed on the Assessed Priority Consumer List. When funding opens, APS high-risk referrals are released first, followed by imminent-risk cases and Aging Out referrals, and then everyone else in descending priority-score order. Ties are broken by how long each person has been waiting.⁴

Keep your contact information current with the ADRC. If the Department cannot reach you when a slot opens, the opportunity passes to the next person. If a placement is terminated for any reason, the applicant must start the screening over and any previous priority standing is disregarded.

Rescreening If Things Get Worse

If the applicant’s situation deteriorates while on the waitlist, request a rescreening. The ADRC rescreens people with a high priority score annually or when notified of a significant change; those with a low priority score are rescreened on request or when a change is reported.⁴

A significant change means any of the following:⁷

A change in health status after an accident or illness.
An actual or expected change in living situation.
A change in the caregiver relationship.
Loss of or damage to the home, or a decline in the home environment.
Loss of a spouse or caregiver.

Call the ADRC as soon as one of these happens. The rescreening covers the same domains as the original 701S and produces an updated score.

What Happens After You’re Released From the Waitlist

Coming off the APCL is not the same as being enrolled in services. When a slot opens and the Department authorizes release, the ADRC schedules a comprehensive assessment on the DOEA 701B form, a more detailed evaluation that produces a full picture of care needs. The applicant must also meet Medicaid financial eligibility for the SMMC LTC program, and the ADRC can help determine whether the applicant meets those thresholds. Once eligibility is confirmed and the 701B is complete, the applicant is enrolled in a managed care plan that coordinates home and community-based services, which can include personal care, homemaker assistance, adult day health care, home-delivered meals, respite care, medical equipment, skilled nursing, therapies, medication management, personal emergency response systems, and home accessibility modifications.³

1
Elder Affairs Florida. Aging and Disability Resource Centers
2
Elder Affairs Florida. Forms
3
Medicaid. Demonstration and Waiver List
4
Florida Legislature. Florida Statutes 409.979 – Eligibility
5
eCFR. 42 CFR 435.910
6
Agency for Health Care Administration. 59G-4.193 SMMC LTC Waiver Prioritization and Enrollment
7
Agency for Health Care Administration. SMMC Long-Term Care Program Screening