Commissioners endorse Sandhills Center proposal - News 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out Section 1. Enter the Date of Submission, Network Provider Agency Name, and Contact Name. Ensure that you provide accurate mailing address details including city, state, and zip code.
3. Continue with the Beneficiary’s information: Name, Age, Date of Birth, and County of Medicaid origin. Don’t forget to include the Care Coordinator’s Name.
4. Indicate whether the member is living in their natural home by selecting 'Yes' or 'No'. Then proceed to fill in the Prospective Employee’s Name and their relationship to the Beneficiary.
5. In Section 2, specify how many total hours are requested per week for Community Living and Support. Answer questions regarding Backup Staffing requirements.
6. Complete Section 3 by attesting that no other qualified provider is available and provide justifications as required. Make sure to explain your plans for ensuring community integration.
7. Finally, review all sections for accuracy before signing. Ensure all signatures are obtained where necessary before submitting the form.

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