R ICF/MR APPLICATION AND SERVICE DELIVERY PREFERENCE FORM I. CONFIRMATION OF UNDERSTANDING I, , have been informed of the following: (NAME OF INDIVIDUAL) a. That I am likely to require the level of care provided in an Intermediate Care Facility for people with Mental Retardation (ICF/MR). I understand that this is based on a preliminary determination of eligibility for ICF/MR level of care, and that the determination will.
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How to fill out the Dp 457 Form online
The Dp 457 Form is an essential document for individuals requesting services from the Department of Public Welfare's Office of Developmental Programs. This guide provides a clear and systematic approach for filling out this form online, ensuring ease of completion for all users.
Follow the steps to fill out the Dp 457 Form online accurately.
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- Begin with the confirmation of understanding section. Enter the name of the individual and indicate their understanding of the necessary care level. Be sure to review the listed points regarding eligibility and service alternatives.
- Proceed to the designation of service preference. Indicate the user's choice by placing initials or a mark beside one option: home and community-based services funded under the Waiver, services in an ICF/MR, or 'none at this time' if applicable.
- In the application section, the individual must confirm their application by entering their name, with initials or a mark next to each understanding of the service desire and assessment process.
- Complete the participant information section for the individual requesting services. Input the individual's name, access number, current address, city, state, zip code, telephone number, signature, and the date.
- If applicable, fill out the surrogate section. Include the name, address, telephone number, signature, and date to represent the individual's choices.
- Have the independent qualified mental retardation professional complete their section with relevant details, including their name and agency, and provide their signature and date.
- Lastly, the designated representative from the County MH/MR Program/Administrative Entity must complete their section, providing all necessary information, signature, and date.
- Review all entries for accuracy and completeness. Save your changes to ensure all information is retained. You may then choose to download, print, or share the completed form as needed.
Take action now and complete your Dp 457 Form online to ensure timely processing of your service request.
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