1199seiu waiver 2026

1. Click ‘Get Form’ to open the 1199SEIU waiver in the editor.
2. Begin by filling out the 'Request Submitted By' section, including the request date in MM/DD/YYYY format.
3. In the 'Patient Information' section, enter the member's full name and ID number. If applicable, provide the patient's full name and date of birth.
4. Indicate whether the patient resides at home or in a facility by selecting 'Yes' or 'No'. If they are in a facility, specify the date they became a resident.
5. Complete questions regarding medication requirements and pharmacy participation, ensuring to provide an effective date for the waiver.
6. If applicable, fill out information regarding Medicare and Medicaid enrollment, including effective dates.
7. Provide details for any designated Power of Attorney and pharmacy information as required.
8. List all prescription medications with their names, dosages, and frequencies.
9. Finally, have the authorized facility administrator sign and date the form before submission.

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