Get New Participant Fea Referral Form - Public Partnerships

The New Participant FEA Referral Form is a crucial document used for re-enrollment, transfers, or when the portal is unavailable. This guide will provide clear, step-by-step instructions to help you complete the form accurately and efficiently online.

Follow the steps to fill out the form online

1. Press the ‘Get Form’ button to access the form and open it in your preferred online form editor.
2. Fill in the referring agency details, including the date, service coordinator's name, phone number, agency, supervisor details, and email. Make sure that this information is accurate to facilitate communication.
3. Select the applicable program from the list provided, such as OBRA Waiver, Attendant Care Waiver, or other options as relevant to your situation.
4. Indicate the referral type by checking the appropriate box, whether it is a new referral, an options transfer, or re-enrollment.
5. Provide the new participant's information, including their last name, first name, social security number, date of birth, Medicaid ID, gender, ICD-9 code, and physical address.
6. If the mailing address differs from the physical address, fill in the mailing address fields, ensuring that you include city, state, zip code, and a contact phone number.
7. Enter the primary language and alternate phone number for the participant. Next, provide the emergency contact's name, phone, and address, along with their relationship to the participant.
8. If the common law employer information is different from that of the participant, fill out the fields regarding their name, social security number, physical address, and contact information.
9. Review the completed sections for accuracy before submission.
10. Once all information has been entered and reviewed, save your changes. You may download, print, or share the completed form as needed.

Complete your New Participant FEA Referral Form online today for a smoother process.