Get Adap Enrollment Revision Form - Adph

This guide provides comprehensive instructions on completing the ADAP Enrollment Revision Form - Adph online. It is designed to assist users in accurately filling out the form to facilitate enrollment revisions.

Follow the steps to successfully complete your enrollment revision request.

1. Click ‘Get Form’ button to access the ADAP Enrollment Revision Form and open it in your preferred editing tool.
2. Enter the clinic name in the designated field at the top of the form.
3. Input the name of the clinician or doctor responsible for this enrollment revision.
4. Fill in the case worker’s name and email address to ensure they are contacted regarding the revision.
5. Specify the date you are submitting the form to the eligibility office.
6. Provide the client’s full name, ensuring that it matches the records in the system.
7. Enter the date of birth in the specified format along with the social security number and ADAP ID number.
8. Circle all reasons for the enrollment revision, and provide the requested dates for each reason selected.
9. If applicable, explain any other reasons for the enrollment revision in the ‘Other Reason’ field, including a date.
10. Review all the information entered to ensure accuracy and completeness.
11. Once completed, save the changes to the document. You can then download, print, or share the form as needed.

Complete the ADAP Enrollment Revision Form online today to ensure your enrollment revision is processed effectively.