Get Appendix B Level Of Care Determination Notice

Filling out the Appendix B Level Of Care Determination Notice is an important step in the assessment process for individuals seeking care services. This guide provides clear and concise instructions for completing the form online to ensure that all necessary information is accurately provided.

Follow the steps to fill out the form correctly

1. Click ‘Get Form’ button to obtain the form and open it for completion in your online editor.
2. In the upper left corner, enter the name of the individual, guardian, or responsible party. Ensure this information is clear to identify who the notice pertains to.
3. In the upper right corner, fill in the individual’s name, address, and Social Security Number. This information is essential for proper identification.
4. Specify the level of care determination by selecting one of the following options: A. Nursing Facility Clinically Eligible, B. Nursing Facility Ineligible. Ensure to provide a comment if necessary as instructed.
5. If the individual is applying for OLTL Waivers without an MA51/script and has exceeded the 15-day requirement, indicate this by marking C. Other and provide relevant details in the comments section.
6. In the assessment unit section, provide the name and address of the assessing agency, along with a contact telephone number.
7. The form must be signed and dated by the assessor or their designee, which could be a supervisor or lead worker responsible for the assessment.
8. Finally, ensure that a copy of the Determination Notice is sent to the individual or their guardian, is attached to each medical evaluation form sent to the local County Assistance Office, and is retained in the individual’s case record.

Complete your documents online efficiently and accurately.