Get Unmet Needs Request Application Final - West Virginia Department ... - Dhhr Wv

The Unmet Needs Request Application Final is essential for individuals seeking financial assistance for various health-related services through the West Virginia Department of Health and Human Resources. This guide provides clear, step-by-step instructions to help users navigate the application process efficiently.

Follow the steps to successfully complete the application online.

1. Press the ‘Get Form’ button to access the application and open it for completion.
2. Fill out the 'Date of Application' field, ensuring you write the current date.
3. In the 'Name of Applicant who will use Funds' section, enter the full name of the individual who requires the funds.
4. For the 'Name of Service Coordinator, Agency, Phone & Email' section, provide the relevant contact information for the service coordinator assigned to assist the applicant.
5. Input the diagnoses of the individual, followed by the date of birth in the format of MM/DD/YYYY.
6. Indicate if the individual has a guardian by selecting yes or no.
7. Answer whether the individual is a member of the Medley Class by choosing yes or no.
8. State if the individual is a Title XIX Waiver Applicant by selecting yes or no.
9. Provide the age of onset by entering the corresponding date in MM/DD/YYYY format.
10. Specify the type and amount of income the applicant receives.
11. Indicate if other sources of funding or Medicaid were requested or denied, and attach proof of any denial.
12. Describe the living arrangements of the consumer in the designated area.
13. In the 'Intellectual Disabilities Unmet Needs' section, list the services requested along with the total amount requested for each.
14. For each service, also provide any amount that was denied by Medicaid/Medicare/Insurance.
15. Attach any supporting documentation as specified in the attachment list.
16. Write a narrative explaining the request for assistance.
17. Obtain the necessary signatures from the consumer or guardian, case manager, and team members.
18. Once all information is filled out, you can save changes to the form, download it, print it, or share it as needed.

Complete your Unmet Needs Request Application online today to secure the supports you require.