Get Form 3617

Filling out the Form 3617 is an essential step in transferring waiver program services, ensuring that the necessary information is accurately documented. This guide will provide you with a clear and step-by-step approach for completing the form online, tailored for users of all experience levels.

Follow the steps to successfully complete the Form 3617 online.

1. Click ‘Get Form’ button to obtain the form and access it for completion.
2. Fill in the 'Individual Information' section. This includes the transfer effective date and the waiver program. Enter the CARE/client ID along with the individual's last name and first name. Make sure to select the appropriate agency as the receiving program provider.
3. Complete the 'Local Authority and Service Coordinator Information' section. Provide the local authority name, local authority comp code, service coordinator's area code and telephone number, fax number, and email. Ensure that the service coordinator’s details are accurate.
4. In the 'Transferring Program Provider Information' section, the transferring program provider will need to provide their legal name (without using a DBA name), comp code, vendor/contract number, and contact details. This section must be signed by the transferring program provider.
5. Next, complete the 'Receiving Program Provider Information' section similarly. Enter the legal name, comp code, vendor/contract number, and contact information for the receiving program provider. This section also requires a signature.
6. If applicable, fill in the 'Section III - Transferring CDSA Information' and 'Section IV - Receiving CDSA Information'. Provide the necessary details such as legal name, comp code, vendor/contract number, and contact information. Both sections require the representative's signature.
7. If there are no CDSAs involved in the transfer, skip the relevant sections as noted in the form. Similarly, if the transfer does not need immediate action, make sure the appropriate criteria are addressed.
8. Complete the IPC details, adding the necessary service information into the provided columns, including units/dollars for both transferring and receiving providers.
9. Finally, review all entered information for accuracy. You may then save your changes, download the completed form, print it, or share it as needed.

Start completing your Form 3617 online to ensure a smooth transfer of services.