Get Css Enrollment/admission Form

Completing the CSS enrollment/admission form online is a straightforward process that ensures your information is accurately captured. This guide will walk you through each section of the form, making the process clearer and aiding you in submitting your details efficiently.

Follow the steps to complete the form with ease.

1. Click ‘Get Form’ button to obtain the form and open it in the editor for online completion.
2. Begin by filling in the consumer name, ensuring you include both the last and first name, as well as the referral source, indicating where the referral originated.
3. Specify the enrollment date, marking the date on which the consumer was determined eligible for CSS based on medical necessity criteria, along with the admission date to the community.
4. Select the consumer's gender and enter their date of birth in the format M/D/YYYY, which is essential for identification purposes.
5. Enter the consumer's Medicaid number if applicable, followed by any Medicare number, ensuring these records are accurate for billing and insurance purposes.
6. Fill in the section for NJ state funding or commercial insurance by naming the insurance company, alongside the relevant policy number.
7. Indicate the CSS initiative applicable to the consumer from the provided options, giving clarity on the care being received.
8. Complete the details regarding the consumer’s county of residence, CSS service provider's name, address, and contact information, including phone, fax, and email.
9. Input the agency staff or credential and the CSS Medicaid provider number for accurate documentation.
10. Finally, ensure to provide a signature and the date of completion. Review all entries for accuracy before submitting.
11. Once you have filled out all necessary fields, you can save changes, download, print, or share the completed form as needed.

Start filling out documents online today to ensure your information is submitted efficiently.