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Click ‘Get Form’ to open the cf es 2506a in the editor.
Begin with Section A: Resident’s Information. Enter the resident's name and ensure all details are accurate.
Proceed to Section A.1: Representatives Information. Fill in the representative's name, SSN, address, date of birth, Medicaid ID number, telephone number, and relationship to the resident.
In Section B, indicate if the individual is an SSI Direct Enrollee by selecting 'Yes' or 'No'. Complete the Active Aid Category/Coverage Group and admission details.
For Section C, provide discharge information including the date of discharge/transfer and specify where the resident is being transferred to.
Finally, complete Section D by notifying DCF about any changes in managed care plans along with effective dates and contact information for the Managed Care Plan.

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