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Dads fprm 3625-2026
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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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