Get Mental Health Waiver Request Form - Ct.gov - Ct

Completing the Mental Health Waiver Request Form is an essential step in accessing necessary mental health services. This guide provides a straightforward approach to filling out the form accurately and efficiently.

Follow the steps to successfully complete the Mental Health Waiver Request Form.

1. Press the ‘Get Form’ button to access the form and open it in your preferred editor.
2. Fill in your name in the designated field at the top of the form. Ensure all spelling is correct and legible.
3. Provide the name of your nursing facility in the corresponding section to ensure clear communication.
4. In the address fields, enter your community address, city, and zip code accurately. This information is crucial for service delivery.
5. Enter your telephone number and cell phone number, making sure to check for accuracy.
6. Input your date of birth in the required format so that the processing of your request can be verified.
7. Indicate your marital status by selecting the appropriate option: single, divorced, widowed, or married.
8. Fill in your Medicaid ID number and Social Security number in the specified sections, ensuring the information is accurate and up-to-date.
9. Identify your referral source and their relationship to you, checking whether this is self, family, conservator of person, or other.
10. State your mental health diagnosis clearly, providing any necessary details or examples that may support your request.
11. List your current community providers along with their phone numbers to facilitate coordination of care.
12. Indicate your Activities of Daily Living (ADL) needs by checking the relevant boxes to summarize the support you require.
13. In the cognitive impairment section, provide necessary details related to orientation, planning, and other areas as applicable.
14. Sign the application in the designated area and date it to confirm the information provided is accurate.
15. Submit the request from your provider, ensuring that it includes psycho-social history, functional assessment, and current recovery plan.
16. Fax the completed form along with the required clinical information to (860) 262-5852.
17. Ensure you save a copy of the filled form for your records. You may also download, print, or share the form as needed.

Complete your Mental Health Waiver Request Form online today for timely assistance.