Follow the steps to successfully complete the form.

1. Press the ‘Get Form’ button to access the form and open it in your editor.
2. In the first section, enter the name of your Medicaid certified provider and the Medicaid provider number accurately.
3. Provide the contact person's name, along with their telephone number and email address.
4. Indicate whether the Medicaid certified provider will be performing personal care screens directly by selecting 'Yes' or 'No.'
5. Answer if the Medicaid certified provider is already established as an agency for the Adult Long Term Care Functional Screen, Children's Long Term Support Screen, or Mental Health/AODA Screen.
6. State whether contract agencies will be conducting personal care screens on behalf of the Medicaid certified provider and answer accordingly.
7. If you answered 'Yes' to the previous question, fill in the names and contact information of all agencies conducting personal care screens. Ensure that each agency name, contact name, telephone number, and email address is complete.
8. Provide the contact information for the individual to whom the application should be submitted, including their name and email address.
9. Review the information provided in the form for accuracy and completeness.
10. Once you have verified all information, you can save your changes, download, print, or share the completed form as needed.

Complete your application online today to access the personal care screening tool.