Dads form 8606 a-2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the individual's name and Medicaid number at the top of the form. This information is crucial for identifying the recipient of services.
3. Next, fill in the Case Management Agency (CMA) Name and CMA Vendor Number. These details help link the request to the appropriate agency.
4. Specify the requested skilled or specialized therapy. Be clear and concise to ensure proper understanding of needs.
5. List any non-waiver resources that were exhausted prior to this request. This section demonstrates due diligence in seeking alternatives.
6. The case manager must sign and date the form, confirming their involvement and approval of the request.
7. For professional input, provide a diagnosis and a brief description of the need for services. Detail specific qualifying conditions requiring treatment.
8. Outline planned interventions with baseline data, goals, objectives, implementation plans, and service details including scope, duration, amount, frequency, and location.
9. Indicate whether components of requested services can be delivered by someone other than a therapist. If no, describe those components requiring a licensed professional.
10. Finally, include a plan for transferring therapy services to a non-therapist if applicable. The supervising therapist must sign and provide their printed name, title, contact information, date, and license number if necessary.

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