Get Cip F 21051

Filling out the Cip F 21051 form is essential for users seeking community long-term care services in Wisconsin. This guide provides clear, step-by-step instructions to assist you in completing the form online with ease.

Follow the steps to successfully complete the Cip F 21051 form online.

1. Click ‘Get Form’ button to obtain the Cip F 21051 form and open it in your preferred editing environment.
2. Begin by entering the applicant’s Social Security Number and Medicaid Number if different. This information is crucial for identification purposes.
3. Fill in the applicant's name by entering the last name, first name, and middle initial in the designated fields.
4. Provide the applicant's street address, including city, state, and zip code to ensure proper correspondence.
5. Enter the applicant's date of birth in the specified format provided in the form.
6. Include a telephone number where the applicant can be reached.
7. Indicate the marital status of the applicant by checking the appropriate box (Single, Divorced, Married, Widowed).
8. Describe the living arrangement by selecting one of the options provided, including specifying if 'Other' is applicable.
9. Fill in the contact person's name, telephone number, and their relationship to the applicant. This could be a guardian, financial representative, or any authorized person.
10. Specify the date of the initial request for community waiver and include details about whether the applicant is a 'transfer' to or from a Family Care County.
11. Enter the anticipated waiver start date and the date of referral from the care manager or support and service coordinator.
12. List the name and telephone number of the care manager or support and service coordinator assisting with the application.
13. Select the appropriate long-term care program target group eligibility by checking one of the options listed.
14. Indicate the level of care (LOC) required by selecting one of the choices provided for PACE/Partnership Agencies.
15. Provide information about functional eligibility by selecting 'Yes' or 'No' as applicable.
16. Enter any special housing amounts if applicable, along with the costs of monthly out-of-pocket remedial and medical expenses.
17. Select a plan for processing the application, indicating if the care manager or IM worker will arrange appointments.
18. Review all information filled out to ensure accuracy before submitting the form.
19. Once the form is completely filled out, you can save changes, download, print, or share the completed form as necessary.

Complete your Cip F 21051 form online today to ensure efficient processing of your community long-term care services request.