Get Ldss 5023

The Ldss 5023 is the Congregate Care Change Report Form required for reporting changes in care arrangements. This guide will provide you with clear, step-by-step instructions to assist you in completing the form online.

Follow the steps to successfully complete the form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin with Client Identification. Fill in the name, last four digits of the Social Security number, and date of birth. Input the new residence address and mailing address if it differs from the residence address. Then, provide the new and former provider names and addresses, along with the respective county information.
3. In the Nature of Placement section, indicate the type of placement and care. Select whether this is a move into or moved out of congregate care for Levels 1, 2, 3, or a medical facility. Specify other types of moves if applicable, along with the effective date(s) of the change.
4. Complete the Custody section if applicable. Indicate who has legal custody for children under 18 years old by selecting from the options provided: Parent/Guardian, Social Services, or Other.
5. In the Income Changes section, specify the type of income, the amount, and the date when the income changed.
6. For Resources, enter the total countable resources and the effective date of this information.
7. If you are requesting direct deposit for benefits, complete the Authorization for Direct Deposit section by filling in the bank name, address, and account details, along with necessary signatures.
8. In the Authorization section, provide your name, signature, title, date, telephone number, and email address.
9. Once the form is fully completed, save your changes. You should also consider downloading, printing, or sharing the form as needed before returning it to the specified contact methods.

Complete your Ldss 5023 form online now to ensure timely processing of your changes.