
Program services. See WAG 20-28-01. (Note: Enter Social Security Number for new applicant only). CASE LOAD NUMBER (if available): This is to notify the FCRC that the person named above receives services from the Department on Aging (DoA) Community Care Program (CCP). 1. STATUS OF MEDICAID ELIGIBILITY (CHECK ONE) The person named above has completed an application for medical benefits. Form 2378H is attached. The person named above has an active medical case. 2. STATUS OF COMMUNITY CARE PRO.
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How to fill out the Hfs 2538b Form online
The Hfs 2538b Form is essential for notifying the Care Coordination Unit about services received under the Department on Aging's Community Care Program. This guide provides clear guidance on how to accurately complete the form online to ensure proper documentation and communication with relevant agencies.
Follow the steps to successfully complete the Hfs 2538b Form online.
- Click ‘Get Form’ button to obtain the form and open it for editing.
- Begin by entering the name of the person receiving services in the designated field labeled 'NAME'. Ensure that the name matches official records for consistency.
- In the 'ADDRESS' section, input the complete mailing address of the individual. This should include city, state, and zip code.
- Provide the contact person's information including their name and phone number to ensure easy communication regarding the case.
- Fill in the 'CASE ID' to uniquely identify the individual’s case. If you do not have a case ID yet, leave this section blank.
- Check the appropriate box under 'STATUS OF MEDICAID ELIGIBILITY'. If the individual has completed a medical benefits application, ensure that Form 2378H is attached if required, or check if there is an active medical case.
- Under 'STATUS OF COMMUNITY CARE PROGRAM (CCP) SERVICES', indicate whether the individual is currently receiving services and specify the effective date. Also, record the monthly costs of the services.
- For the 'CHANGE OF INFORMATION' section, check any applicable boxes, including updates regarding the client’s death, termination of services, or changes to their living situation, along with the relevant dates.
- Review all entries for accuracy and completeness to ensure that all necessary fields are filled out properly.
- Once completed, save the changes made to the form. You can then choose to download, print, or share the form as needed.
Complete your Hfs 2538b Form online today to ensure timely communication and processing of services.
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