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Get Icfmr Program Tennessee Form
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How to fill out the Icfmr Program Tennessee Form online
This guide provides a thorough overview of how to accurately complete the Icfmr Program Tennessee Form online. By following the steps outlined below, users can ensure that they provide all necessary information for a smooth transition within the program.
Follow the steps to fill out the form effectively:
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- Begin by filling out section A: Recipient Information. Enter the recipient's name including last, first, and middle names. Additionally, provide the date of birth, social security number, and Medicaid number.
- Move to section B: Submitter’s Contact Information. Input the name of the person submitting the form, along with their phone number and email address. Don't forget to include the regional office associated with the case.
- Proceed to section C: Member Representative. Here, enter the member representative's name, address, city, state, and zip code. Provide their phone number as well.
- In section D: Transferring Facility, fill out the provider number, address, city, state, zip code, and phone number of the facility. Specify the transfer (discharge) date and the current MR program, indicating whether it is ICF/MR or HCBS.
- Next, complete section E: Admitting Facility. Fill out the required details such as provider number, address, city, state, zip code, contact person, and phone number. Specify the patient liability amount and effective date of patient liability.
- Indicate the transfer (admission) date and the requested MR program in section F. Specify whether it is ICF/MR or HCBS.
- For section G, outline the plan of care. If it pertains to HCBS waiver-covered services, include the amount, frequency, and duration. For ICF/MR, detail all habilitative services, including residential requirements.
- The final part of the form will be completed by TennCare. Ensure that the form is submitted in its entirety. Once filled, review the information for accuracy, then save, download, print, or share the completed form.
Start completing your Icfmr Program Tennessee Form online now.
Becoming a choice provider in Tennessee involves several steps. First, you must meet the state's qualifications and understand the requirements for services offered. Completing the Icfmr Program Tennessee Form is a critical part of the application, along with attending training and orientation sessions. By becoming a provider, you can make a meaningful impact on the lives of individuals in the community.
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