Follow the steps to successfully complete the online form.

1. Press the ‘Get Form’ button to obtain the 1800755grow Form and open it in the designated editor.
2. Begin by checking the appropriate box at the top of the form that corresponds to the purpose of your application, such as diagnostic, treatment, or case renewal.
3. Fill in the demographic and identifying information for the child or client, which includes their name, case number, address, county, birthdate, and Social Security number.
4. Provide the parent’s or legal guardian’s information, including their name and contact details, in the designated fields.
5. Complete the insurance information section. This includes details on health, dental, and vision coverage, as well as Medicaid eligibility, making sure to provide required policy numbers.
6. Identify the managing physician or service coordinator by providing their name, site of visit, address, and contact information.
7. List all eligible diagnoses and their corresponding ICD codes in the indicated fields.
8. On the back of the form, describe major services requested and the providers for each service, ensuring to include any necessary documentation or medical reports.
9. Ensure that the managing physician or service coordinator signs the form, including the date and their printed name, verifying the information provided.
10. Finish by signing and dating the form yourself or by the client if they are over 18 years of age, along with providing any additional requested information.
11. Once all sections are filled out accurately, save your changes, download the completed form, print it, or share it as needed.

Start filling out the 1800755grow Form online today for a smooth application process.