Get (spoa) Care Coordination /act Program Application Cover Sheet - Cucs

Filling out the (SPOA) Care Coordination /ACT Program Application Cover Sheet - Cucs online can be a straightforward process when you follow the right steps. This guide offers clear, detailed instructions to help you complete each section of the form efficiently.

Follow the steps to accurately complete the application cover sheet.

1. Press the 'Get Form' button to access the application cover sheet and open it for editing.
2. Begin by entering the date of submission in the designated field at the top of the form. This is crucial for tracking your application.
3. Fill in the 'FROM' section with the referring agency information, including the program name, referring worker’s name, contact phone, fax, and email.
4. In the 'TO' section, ensure the recipient information is accurately listed as SPOA Care Coordination /ACT Program.
5. Complete the 'RE:' section with the applicant's last name and date of birth, as well as their first name.
6. Select the level of service requested by circling the appropriate option — Non-Medicaid Home Care Coordination, ACT, or Health Home Care Coordination.
7. Indicate the type of referral by circling all applicable options in the given section. This helps prioritize the applicant's needs accurately.
8. Fill in the ‘CONSENT TO RELEASE INFORMATION’ section to authorize the release of applicant information for care coordination.
9. Provide the applicant's name and the witness name as required at the bottom of the consent section, along with their signatures and dates.
10. Ensure that the document is complete by confirming all necessary supporting documents are included before submitting the entire packet.
11. After completing the application, save the changes and proceed to download, print, or share the cover sheet as required.

Begin filling out the (SPOA) application online today to ensure timely processing of your application.