Get H1700 A1

Filling out the H1700 A1 form is an essential step in certifying the completion or delivery of HCBS STAR+PLUS waiver items and services. This guide provides clear, step-by-step instructions to help users complete the form accurately and efficiently.

Follow the steps to complete the H1700 A1 form online.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. Begin by entering the applicant's or member's name in the designated field. It is important to ensure this name matches the official documents.
3. Next, input the Medicaid number associated with the applicant or member. Double-check this number for accuracy as it is crucial for processing.
4. Provide the name of the provider or vendor who is contracted to complete or deliver the HCBS STAR+PLUS waiver items or services. This should be the official name recognized by the contracting agency.
5. Specify the HCBS STAR+PLUS waiver item(s) or service(s) that are being certified. Be as detailed as possible to ensure clarity.
6. Enter the completion or delivery date in the appropriate field. This date should reflect when the services were actually completed.
7. The form requires a signature from an MCO representative to certify that the services were completed satisfactorily. Ensure this person reviews the preceding information before signing.
8. Lastly, the member must also sign the form to confirm that they are satisfied with the completion of the services provided. Include the current date next to the member's signature.
9. Once all fields are completed and signatures are in place, you can save your changes, download, print, or share the form as needed.

Complete your H1700 A1 form online today for efficient processing of your HCBS STAR+PLUS waiver items and services.