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Click ‘Get Form’ to open it in the editor.
Begin by filling out Section A, which includes the Applicant/Individual Information. Enter the name, Social Security Number, and Medicaid Number as required.
Proceed to Section B for Provider Agency Information. Specify the Agency Type, Agency Name, and Vendor Number.
In Section C, indicate the Pre-Enrollment Assessment Fees by selecting either Full or Partial Assessment for Case Management Services and DSA Services.
Complete Section D by providing the Case Manager's Name and indicating if Case Management Services are ongoing.
For Section E, choose a Method of Delivery and fill in relevant details such as Service Category and any applicable Requisition Fees.
Document time in Section F by recording each day’s service hours along with units and amounts. Ensure total units/amount are calculated accurately.
Finally, complete Section G by obtaining necessary signatures from the person delivering services, the applicant/individual/LAR, and the timekeeper along with their respective dates.

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Versions	Form popularity	Fillable & printable
2015	4.8 Satisfied (203 Votes)
2010	4 Satisfied (51 Votes)
2003	4.6 Satisfied (51 Votes)

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