Get Request For Screening For - Dmas Virginia

Filling out the REQUEST FOR SCREENING FOR - Dmas Virginia is an important step towards accessing developmental disabilities support services. This guide provides a clear and supportive walkthrough of the process, ensuring that all potential users can easily understand and complete the required form.

Follow the steps to accurately complete the form for screening.

1. Press the ‘Get Form’ button to access the form and open it for editing.
2. Begin by clearly printing the name of the parent or responsible party in the designated field.
3. Provide your home phone number, including the area code, followed by your work or cell phone number.
4. Next, print the name of the person who is to be screened, ensuring that you include their last and first names.
5. Indicate the gender of the person being screened by checking either the box for 'Male' or 'Female'.
6. Fill in the date of application in the specified field.
7. Enter the complete address of the person being screened, including street address, city, state, and zip code.
8. If applicable, provide the county information.
9. Fill in the date of birth of the person being screened along with their age and Social Security number.
10. Confirm eligibility by answering whether the individual is currently Medicaid eligible, and if yes, include their 12-digit Medicaid number.
11. List any services currently received under Medicaid.
12. Include the signature of the person making the request for screening, along with their printed name.
13. Indicate the relationship to the person being screened.
14. If the phone number of the person making the request differs from the one initially provided, enter it in the appropriate field.
15. Ensure that the completed form is mailed to the nearest Screening Facility, such as a Child Development Clinic or Health Department.
16. Finally, review all entries for accuracy and completeness before submitting the form.

Get started now by completing the REQUEST FOR SCREENING FOR - Dmas Virginia form online.