Get Dodd Loc Date Change Request Form

This guide provides detailed instructions on how to complete the Dodd Loc Date Change Request Form online. By following these steps, users can effectively submit their requests for changes to their level of care dates.

Follow the steps to complete the Dodd Loc Date Change Request Form

1. Press the ‘Get Form’ button to obtain the Dodd Loc Date Change Request Form and open it in your online editor.
2. Begin by filling out your first and last name in the designated fields at the top of the form.
3. Select your current waiver type by checking the appropriate box: Lv1, IO, or SELF.
4. Provide your county information in the specified field.
5. Enter your DODD number in the provided section.
6. Fill out the current LOC date fields, including both the start date and end date.
7. Indicate the new LOC date by entering the new start date and end date, ensuring that the new start date is before the end date of the current LOC.
8. In the reason for changing the LOC date section, clearly articulate the reason for your request, and specify if it involves a classification change.
9. Reference the LOC Date Change Checklist at the end of the form to ensure all required submissions are prepared.
10. Once you have completed all necessary sections, review your entries for accuracy. Then proceed to save your changes, download or print the completed form, or share it as needed.

Take the first step now and complete your Dodd Loc Date Change Request Form online.