Decline of Offer for CLASS Program Enrollment - The Texas 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the 'Name of Applicant' in the designated field. Ensure that the name matches official documents for accuracy.
3. Fill in the 'Area Code and Telephone Number' to provide a means of contact.
4. Complete the 'Mailing Address' section with your full address, including street, city, state, and ZIP code.
5. Input your 'Medicaid Number' if applicable, as this is crucial for identification purposes.
6. If there is a Legally Authorized Representative (LAR), include their name in the respective field.
7. Provide the 'Applicant's Date of Birth' to verify eligibility.
8. Fill out details regarding your Case Management Agency (CMA), including the agency name and contact information.
9. In the section regarding declining participation, clearly state your reason for declining if desired.
10. Finally, ensure both signatures are provided: one from you or your LAR and another from a CMA representative along with dates.

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