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1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the individual’s information, including their Name, Date of Birth (DOB), and TABS ID. If applicable, indicate if the child is under age 18 and requesting a waiver of Parental Deeming.
3. In the 'Services Requested' section, select the appropriate Service Type from the drop-down list. For each service, specify the Annual Service Units if applicable and provide a brief Explanation of Need for Service.
4. Fill in the Care Coordination Organization (CCO) Information by entering the CCO Staff Name, selecting the CCO from the drop-down list, and providing contact details including Email and Phone.
5. Complete the CCO Signature and Attestation section by signing and dating the form to confirm that a comprehensive conversation about needs has occurred.
6. Finally, submit your completed form along with any required supporting documents as instructed.

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