Form 142 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Social Security Number (SSN) and Date of Birth in the designated fields at the top of the form.
3. Fill in the Medicaid Number, Home Address, and Facility/Provider/Support Coordinator Name along with their Vendor Number and Facility Address.
4. In Section I, indicate eligibility status by checking the appropriate box for Medicaid approval or denial. If approved, specify the Level of Care and any relevant details regarding medical conditions or treatments.
5. Proceed to Section II if applicable. Mark whether a Level II decision is required and provide dates for approvals or denials as necessary.
6. Complete Section III regarding Waiver/PACE services by indicating approval status and effective dates. Ensure all agency representative signatures are included.

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