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01. Edit your department of public welfare itf waiver pw 123 form online
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How to use or fill out pw 123 certification need infants toddlers with our platform
- Click ‘Get Form’ to open the pw 123 certification in the editor.
- Begin by entering the individual's name, parent/legal guardian's name, and current address in the designated fields.
- Fill in the date of birth and social security number accurately to ensure proper identification.
- In Section I, select either A or B based on whether the individual meets the ICF/MR/ORC level of care criteria. If they do, complete Section A; if not, proceed with Section B.
- Provide your signature, date, address, and telephone number in the appropriate fields to certify your assessment.
- Section II requires input from a County MH/MR Program designee. Ensure they complete their section for final determination.
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