Get Eligibility/ineligibility/change Form

This guide provides clear and supportive instructions on how to complete the ELIGIBILITY/INELIGIBILITY/CHANGE FORM online. Follow these detailed steps to ensure your application is accurate and complete.

Follow the steps to successfully fill out your form.

1. Click 'Get Form' button to obtain the form and open it for completion.
2. Fill out the 'Department of Human Services (DHS) office information' section. Provide the name of the County Assistance Office (CAO) and, if applicable, the District Office name.
3. Complete the 'Applicant/Recipient Identification (RID) Information' section. Enter the individual's name, telephone number, email, Social Security number (SSN), birth date, and address.
4. Indicate if the individual is a new HCBS applicant or a current HCBS/MA recipient by selecting the appropriate option.
5. For new applicants, complete Part I, which verifies the level of care appropriate for HCBS including relevant assessment dates and service start dates.
6. For current recipients, complete Part II for updates, changes, terminations, or transfers by checking the relevant box and providing the necessary information.
7. Complete the 'PA 1768 Originator' section including the submitter's signature, title, and contact information.
8. If applicable, provide the representative's information and relationship to the individual receiving services.
9. Fill in the 'Enrolling Agency Information' section with details about the HCBS provider or MH/ID agency.
10. Add any additional comments or attachments in the 'Comments' section as necessary.
11. Review the completed form for accuracy and clarity, then save changes, download, print, or share as needed.

Complete your ELIGIBILITY/INELIGIBILITY/CHANGE FORM online today to ensure timely processing.