Get Cms Intake Form - Dhss Alaska

Completing the CMS Intake Form is an essential step in ensuring proper assistance for beneficiaries. This guide provides clear, step-by-step instructions to help users navigate the form efficiently, enabling a smooth online submission process.

Follow the steps to successfully complete the CMS Intake Form.

1. Press the ‘Get Form’ button to access the form and open it in your preferred editing tool.
2. Begin by entering the inquiry source information if you are not the beneficiary. Fill in the name, date, organization, relationship to the beneficiary, and a contact telephone number.
3. Next, provide the beneficiary or provider information. Include the beneficiary's name, Medicare number, telephone number, cell phone number, city, state, and indicate the type of Medicare applicable.
4. Check all relevant issue types related to the beneficiary, including Parts A, B, C, and D.
5. If Parts C or D are applicable, note the plan name and number. Additionally, specify the language spoken if it is other than English and indicate whether the beneficiary qualifies for LIS (Low Income Subsidy).
6. Describe the actions taken by the referrer. This includes whether the referrer contacted the plan, made a point of sale inquiry, or attached relevant documents like enrollment confirmations or termination letters.
7. If applicable, provide pharmacy contact information. Fill in the pharmacy name and telephone number, along with a relevant contact person.
8. Finally, review all entered information for accuracy, and save your changes. You can then choose to download, print, or share the completed form.

Start filling out your CMS Intake Form online today to ensure your request is processed efficiently.