Get Fsp Disenrollment Form - File Lacounty

The FSP Disenrollment Form is essential for individuals who wish to discontinue their participation in the Full Service Partnership program. This guide provides step-by-step instructions to assist users in accurately completing the form online.

Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to access the FSP Disenrollment Form and open it in your preferred editor.
2. Fill in the date of the request at the top of the form.
3. Specify the client’s demographic details, including their last name, first name, date of birth, and Social Security number.
4. Indicate the enrollment date and the requested disenrollment date for the client.
5. Choose one reason for disenrollment by checking the appropriate box, ensuring that you provide supporting documentation where required.
6. If applicable, provide a brief explanation regarding the target population criteria not being met or document any aftercare arrangements, including referral dates and facility information.
7. Record outreach efforts made to locate the client, referencing any progress notes as needed.
8. If the client has met their goals or is deceased, complete the relevant sections, including the date of death if applicable.
9. Ensure that the 'Impact Unit Decision' section is filled out, including signatures where required.
10. Finally, review your entries for accuracy. Once complete, save the changes, and you may choose to download, print, or share the document as necessary.

Start completing your FSP Disenrollment Form online today to ensure a smooth disenrollment process.