Get Ia 470-0042 2020

The IA 470-0042 form is essential for managing Medicaid applications and case activities within facilities. This guide will provide you with step-by-step instructions on how to accurately complete this form online, ensuring compliance and efficiency.

Follow the steps to effectively fill out the IA 470-0042 form online.

1. Press the ‘Get Form’ button to access the IA 470-0042 form and launch it in the online editing tool.
2. In the 'Member Data' section, enter the applicant or member's name, date of entry into the facility, Social Security number, and state ID. Ensure that the information matches official documents.
3. Proceed to the 'Facility Data' section. Fill in the provider number or NPI number, facility type, Medicaid case number, and facility name. Also, include the street address, city, state, contact name, contact email, and phone number, as well as the date completed.
4. In the 'Level of Care' section, provide details as required. Indicate whether the level of care is determined by IME Medical Services, Medicare, or a managed care contractor. Specify if it pertains to PMIC mental health or substance abuse, where applicable.
5. If Medicare coverage is applicable, complete the Medicare information section with the expected dates of coverage.
6. In the 'Discharge Data' section, document the reason for discharge from the facility, the date of discharge, and the address to which the individual is discharged.
7. Review all entries for accuracy, make any necessary adjustments, and ensure that the signature from the designated person responsible for the information accuracy is included in section 2.
8. After completing the form, save your changes. You can then download, print, or share the form as needed.

Begin filling out your IA 470-0042 form online today to streamline your Medicaid case management.