Get Provider Choice Form

Filling out the Provider Choice Form online is a crucial step in selecting the right service provider for your home and community-based needs. This guide will help you navigate the form efficiently, ensuring you understand each component and make informed choices.

Follow the steps to complete the Provider Choice Form online.

1. Press the 'Get Form' button to obtain the Provider Choice Form and open it in your preferred online editor.
2. Begin by entering your full name, listing your last name first, followed by your first name and middle initial, in the designated field.
3. Input your Participant ID Number accurately in the specified field to ensure proper identification.
4. Read the information provided regarding your rights and options, including that you may interview providers before making a choice.
5. Acknowledge the statements listed on the form by checking each corresponding box, confirming your understanding and choices regarding service provision.
6. Have your service coordinator provide you with a list of potential service providers, and review this list as part of your informed choice process.
7. On the back of the form, indicate your selected service provider for each service listed in your Individual Service Plan.
8. Sign and date the form in the designated areas, ensuring that a representative also signs if applicable.
9. Once completed, save your changes to the form. You may then download, print, or share the completed document as necessary.

Complete your Provider Choice Form online today to take control of your service selection.