Get Cfeec Form 2020-2025

Filling out the Cfeec Form online can streamline the process of requesting non-covered long-term care benefits. This guide provides clear, step-by-step instructions to ensure you complete the form accurately and efficiently.

Follow the steps to successfully complete the Cfeec Form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. In Section 1, fill out the information regarding your Managed Care Plan, including the current Medicaid health plan and the new Managed Long Term Care (MLTC) plan you are transferring to.
3. Move to Section 2 to provide your personal information. Fill in your last name, first name, and Medicaid ID. Indicate your gender, date of birth, contact phone numbers, permanent address, county, state, city, zip code, and email address.
4. If you have an authorized representative, complete their information by providing their last name, first name, address, city, contact phone numbers, county, state, relationship to you, zip code, and email address in the designated fields.
5. In Section 3, review the acknowledgments and releases of medical information carefully. Sign and date both the plan member's signature and the authorized representative's signature where indicated.
6. Proceed to Section 4, where a physician must fill out their information. The physician should confirm the patient’s need for the services listed and provide their signature and the required details about their practice.
7. Finally, in Section 5, the MLTC plan representative should complete the name, title, date, and signature fields to submit the form on behalf of the applicant.
8. Once you have filled out all relevant sections of the form, save your changes, and you have the option to download, print, or share the completed form as necessary.

Complete the Cfeec Form online today to facilitate your request for long-term care benefits.