Ices to: Client’s Name (First and Last) Client’s Date of Birth Provider’s Name (First and Last) Provider Number Provider’s Signature Date If you provide paid service and live with more than one client, you must complete one form for each client you live with. Return attestation form to contracting staff or Case Manager / Social Service Specialist assigned to the client’s case. Important Notice to Individual Providers You may be exempt from Federal Income Tax if you meet the crite.
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How to fill out the WA DSHS 27-113 online
The WA DSHS 27-113 form, also known as the Attestation of Individual Provider’s Living Situation, is essential for individual providers who wish to claim Medicaid Qualified Waiver payments as exempt under IRS Notice 2014-7. This guide will provide step-by-step instructions to help you complete the form accurately and confidently.
Follow the steps to fill out the WA DSHS 27-113 form online.
- Click ‘Get Form’ button to access the document online.
- Begin by entering the client's name in the designated field. Ensure you include both the first and last name.
- Next, provide the client’s date of birth. Input the date format as requested to ensure accuracy.
- In the next section, fill in your own name as the provider. Include your first and last name in the corresponding fields.
- Enter your provider number in the designated field. This identifier is essential for processing your attestation.
- Sign the form in the signature field. Your signature certifies that the information provided is true and accurate.
- Select the current date from the calendar or input it manually in the specified area.
- If you are providing paid service to more than one client, remember to complete a separate form for each client.
- Once all fields are filled out, review the form for any errors or omissions. Make any necessary corrections.
- Finally, save your changes, download a copy for your records, print the form, or share it with the contracting staff or case manager assigned to your client’s case.
Complete the WA DSHS 27-113 form online to ensure your exemption claims are processed smoothly.
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