Get Fm Crcf-01 (june 2014) - Optional State Supplementation

Filling out the FM CRCF-01 form is an important step in requesting optional state supplementation for eligible patients in Community Residential Care Facilities. This guide will provide you with clear, step-by-step instructions to ensure you complete the form accurately and effectively.

Follow the steps to fill out the FM CRCF-01 form online.

1. Press the ‘Get Form’ button to access the FM CRCF-01 form and open it in your preferred online editor.
2. In Section I, provide the identification details of the applicant or resident. Ensure you accurately fill in the applicant/resident’s name, birth date, Medicaid number, CRCF name, county of residence, social security number, CRCF provider ID, request date, and authorized representative’s information.
3. Section II will be completed by the OSS CLTC office. No action is needed from you for this section.
4. In Section III, fill in the type of coverage and statistical data. Indicate if the patient was transferred from another facility or discharged. Also, specify bed hold details if applicable, including start and end dates.
5. Section IV requires information related to Medicaid status. Complete the application date and specify the Medicaid status. The eligibility worker will provide additional details regarding income and payment authorization.
6. After entering all the necessary information, review the entire form for accuracy. If required, Section V must be signed by the eligibility worker, confirming the details provided.
7. Finally, save your changes, then download, print, or share the completed form as needed for submission.

Start completing the FM CRCF-01 form online today!