Get Dads Fprm 3625

Filling out the Dads Form 3625 online is an essential process for documenting services delivered under the Community Living Assistance and Support Services. This guide will provide you with clear, step-by-step instructions to assist you in completing the form accurately and efficiently.

Follow the steps to fill out the Dads Form 3625 online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin the form by entering the service month and year in the designated section.
3. In Section A, provide the applicant or individual’s name. Ensure accuracy in spelling and details.
4. For applicants, enter the social security number in the corresponding field. If the applicant does not have one, leave this blank.
5. Next, input the Medicaid number in the designated space. This is crucial for processing the application.
6. Proceed to Section B to document the provider agency information, including agency type and name.
7. Enter the vendor number for both CMA and DSA in the appropriate fields.
8. In Section C, provide details about case management services by selecting either a full or partial assessment.
9. Fill in the case manager’s name in Section D, followed by the type of case management services provided.
10. In Section E, indicate the method of delivery by checking only one box and providing the necessary names where required.
11. Complete the service category, service code, and associated requisition fee in the relevant fields.
12. In Section F, record the time for each service provided, including time in, time out, units, and amount. Ensure to keep accurate records.
13. Calculate the total units and amount at the end of Section F.
14. Finally, in Section G, obtain the required signatures from the person delivering the service, the applicant or individual/LAR, and the timekeeper. Enter the corresponding dates.
15. Once completed, review the form for any errors, and then save, download, print, or share it as needed.

Start completing your documents online today to ensure timely and accurate submissions.