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- Begin by filling out the Facility Information section. Enter the Facility Name, Submission Date, and the representative's details including their First and Last Name, Title, and Telephone Number.
- Next, move to the Consumer Information section. Input the Consumer’s Name, last four digits of their SSN, Date of Birth, Sex, and Telephone Number. Ensure all information is accurate for proper processing.
- In the Reason for Submission section, indicate whether you are submitting a Medicaid application on behalf of the consumer. Check the appropriate box based on the authorization documents you have attached or if you are attesting to their incapacity.
- Finally, sign the form as a Facility Representative at the bottom. This confirms that all provided information is correct and complete.
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| Versions | Form popularity | Fillable & printable |
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| 2012 | 4.8 Satisfied (308 Votes) |
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