Get Application For Participation Home And Community Based Services ...

Filling out the Application For Participation for Home and Community Based Services can seem daunting, but following a structured approach can simplify the process. This guide offers step-by-step instructions to help you successfully complete the application online.

Follow the steps to fill out the application form successfully.

1. Press the ‘Get Form’ button to access the application form and open it in your online document editor.
2. Begin by entering the applicant's name in the designated field. Ensure that it is the full legal name as it appears on official documents.
3. Provide the current residence of the applicant, including street address, city, state, and zip code.
4. Enter the applicant's telephone number for contact purposes.
5. Fill in the applicant's social security number in the appropriate section.
6. Indicate the date of birth of the applicant, ensuring accuracy in the format required.
7. If applicable, provide the Medicaid number; if the applicant is not enrolled, check the corresponding box.
8. If a Medicaid application is pending, check the appropriate box.
9. Clearly state the request for participation in a Home and Community Based Services Medicaid Waiver.
10. Acknowledge that approval for waiver participation is based on specific eligibility criteria listed in the form.
11. For the TBI Waiver only, confirm that the applicant has a traumatic brain injury and is between the ages of 18 and 64 years.
12. Obtain the applicant's signature in the designated area and date it accordingly.
13. If applicable, have the guardian sign and date the form, along with providing their telephone number.
14. Similarly, if there is an authorized representative, they should sign, date, and provide their telephone number.
15. Review the completed application for accuracy and completeness before submitting.
16. Save your changes, and if necessary, download, print, or share the final version of the form.

Complete your documents online today to ensure timely processing and assistance.