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Form 142 2026
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- Click ‘Get Form’ to open it in the editor.
- Begin by entering the Social Security Number (SSN) and Date of Birth in the designated fields at the top of the form.
- Fill in the Medicaid Number, Home Address, Facility/Provider Name, and Vendor Number as required.
- In Section I, indicate eligibility status by checking the appropriate box for Medicaid approval or denial. If approved, specify the Level of Care and any relevant details regarding physician involvement or treatments.
- Proceed to Section II if applicable. Mark whether a Level II decision is required and provide effective dates for admissions as necessary.
- Complete Section III by indicating waiver services approval status and any associated dates. Ensure all agency representative signatures are included before finalizing.
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