Get Ltc Request For Action - Form 161b

This guide provides comprehensive instructions on how to accurately complete the LTC Request For Action - Form 161B online. Whether you are a healthcare provider or an individual seeking to correct long-term care files, this step-by-step approach will assist you in the process.

Follow the steps to fill out the LTC Request For Action - Form 161B online.

1. Click ‘Get Form’ button to access the LTC Request For Action - Form 161B and open it in the provided editor.
2. Enter the provider’s name in the designated field.
3. Input the provider’s NPI number, area code, and fax number in the appropriate sections.
4. Provide the contact person's name along with their area code and phone number.
5. Select the waiver type and fill in the county number and center number.
6. Enter the recipient’s name, followed by their SSN or Medicaid number.
7. Identify the reason for correcting the long-term care file by checking the relevant box. Include specific details for the requested changes in the provided fields.
8. If applicable, specify any incorrect dates for admission, discharge, or financial eligibility awards. Indicate the required changes in the respective fields.
9. Detail the reason for the requested change or any rejection reason from EDS in the space provided.
10. Once all fields have been completed, review the form for accuracy and clarity.
11. You may then save changes, download, print, or share the completed form.

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