Get Daas 101 Long Form

The Daas 101 Long Form is essential for clients seeking services from the North Carolina Department of Health and Human Services. This guide provides clear and detailed steps to ensure users can complete the form accurately and efficiently online.

Follow the steps to effectively complete the Daas 101 Long Form.

1. Click ‘Get Form’ button to access and open the Daas 101 Long Form online.
2. Begin by completing Section I, which is required for all clients. Enter the Service Code(s), Region Code, and Provider Code as applicable to your situation. Check the appropriate box for Client Status and provide the date of the change.
3. Input the Legal Name, Last Name, First Name, Middle Initial, and any suffix. Provide the Last 4 digits of the Social Security Number and Date of Birth. Enter the Street Address, Mailing Address if different, Phone Number, City, State, Zip Code, and County.
4. Provide information on the Poverty Level and Household Size by selecting the appropriate options for your situation.
5. In Section II, if applicable, answer the Nutrition Health Score questions that assess the client’s dietary habits and challenges.
6. For the care recipient (if relevant), fill out Section III with the Recipient's details, including Name, Date of Birth, Phone Number and address as required.
7. Proceed to Section IV, answering questions about the client or care recipient's memory status and ability to perform daily living tasks.
8. Complete Section V if receiving respite or Family Caregiver Support Program services. Provide required details regarding hours of care needed and provided.
9. In Section VI, the primary caregiver should report their health status and caregiving stress levels.
10. Finally, in Section VII, read through the confidentiality statement, sign to acknowledge understanding, and enter the date of the signature.
11. Once all sections are completed, ensure all changes are saved. You can download, print, or share the completed form as needed.

Complete your Daas 101 Long Form online today to access essential services.