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LONG TERM CARE FACILITIES AND HOME AND COMMUNITY BASED 2026
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- Click ‘Get Form’ to open it in the editor.
- Begin with Section I, 'Estate Recovery'. Read the information carefully and confirm your understanding by signing and dating the designated area.
- Move to Section II, where you will certify your awareness of various waiver services. For each waiver (HCBS, Model Waiver II, BI Waiver), indicate whether consideration is requested or not by checking the appropriate box and signing.
- In Section III, acknowledge your freedom of choice regarding providers by signing and dating the section.
- Proceed to Section IV for Resource Assessment Certification. Again, sign and date after reading the information provided.
- Finally, complete Section V with recipient information. Fill in all required fields including name, address, phone number, Medicaid number, and details of the responsible party.
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