Get Congregate Care Change Form

The Congregate Care Change Form is an essential document for reporting changes in placement or care for individuals in congregate settings. This guide provides a step-by-step approach to filling out the form online, ensuring a smooth and efficient process.

Follow the steps to successfully complete the Congregate Care Change Form online.

1. Press the ‘Get Form’ button to obtain the Congregate Care Change Form and open it in your preferred online editor.
2. Begin by filling out the Client Identification section. Enter the individual's name, the last four digits of their Social Security number, date of birth, new residence address, and new mailing address if different.
3. Provide information on the new provider, including their name and address, as well as the former provider's details. List the counties for both the new and former providers along with their corresponding certificate or license numbers.
4. In the Nature of Placement, Transfer or Other Change section, select the type of placement or care that applies: Congregate Care Level 1, Level 2, Level 3, medical facility, or community/other. Indicate whether it is a move into or moved out of that setting.
5. Specify the effective date(s) for the change in placement or care.
6. Complete the Custody section by identifying who has legal custody of the individual, selecting from options like parent/guardian, social services, or other.
7. In the Income Changes section, indicate the type of income, the amount, and the date the income changed.
8. State the total countable resources in the Resources section, providing the effective date for this information.
9. In the Authorization for Direct Deposit section, fill in the bank account details for the deposit of SSP benefits, including signatures for the payee and the resident.
10. Complete the Authorization section by entering the name, signature, title, date, telephone, and email of the authorized person.
11. Finally, review all entries for accuracy and completeness. You can save changes, download, print, or share the form as needed.

Complete your Congregate Care Change Form online today for a streamlined submission process.