Get Public Partnerships Consumer Directed Attendant Support (cdass) Client Referral Form

This guide provides step-by-step instructions for completing the Public Partnerships Consumer Directed Attendant Support (CDASS) Client Referral Form online. By following these instructions, users can ensure they thoroughly fill out each section of the form accurately.

Follow the steps to successfully complete the CDASS Client Referral Form online.

1. Click the ‘Get Form’ button to obtain the CDASS Client Referral Form and open it for editing.
2. In the Client Information section, fill out the following fields: Name, Waiver, Date of Birth, Social Security Number, Complete Address, Telephone Number, Medicaid ID Number, Alternate Telephone Number, Email Address, Preferred CDASS Start Date, Projected Monthly Allocation Amount, Alternate CDASS Start Date, Monthly Admin Fee, and Preferred Training Mode (if known).
3. In the Authorized Representative (AR) section, determine if the client requires an AR based on the Physician Statement of Consumer Capabilities. If needed, provide the AR's Name, Relationship to Client, Complete Address, Social Security Number, and Phone Number. Indicate what areas of CDASS the AR will manage.
4. Complete the Case Management section by entering the SEP Agency name, Case Manager name, Direct Work Number, Email Address, and any relevant Comments.
5. In the Physician Attestation of Consumer Capacity, have the client’s physician attest to the client’s ability to direct their own care. Fill out details including the Client’s Medicaid Number, Last Name, First Name, Address, Date of Birth, Middle Initial, City, Telephone Number, and indicate whether health conditions are stable.
6. In the Client or Authorized Representative Responsibilities section, acknowledge the responsibilities by filling out the Client's Medicaid Number, Last Name, First Name, and Middle Initial. Review all responsibilities outlined and ensure understanding before signing.
7. In the Authorized Representative Screening Questionnaire, the AR will fill out their information and answer questions regarding their relationship to the client, any payments received, and willingness to serve as an AR.
8. Once all sections are completed, review the form for accuracy. Save changes, and utilize the options to download, print, or share the completed form as necessary.

Complete and submit the Public Partnerships CDASS Client Referral Form online today to ensure timely processing of your request.