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  • Member Request To Transfer

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    CrapHammer
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    This 3 sentence summary provides the key details about a member's request to transfer their care under the Aged and Disabled Waiver Program: The document is a form for a member to request transferring their case management or homemaker agency, or transferring between the traditional agency model and personal options model. The form collects the member's contact and provider information and the reason for the requested transfer. Upon submitting the form, the member will be contacted to explain the transfer process and freedom of choice options.

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    member request to transfer

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    Member Request to Transfer

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    This 3 sentence summary provides the key details about a member's request to transfer their care under the Aged and Disabled Waiver Program: The document is a form for a member to request transferring their case management or homemaker agency, or transferring between the traditional agency model and personal options model. The form collects the member's contact and provider information and the reason for the requested transfer. Upon submitting the form, the member will be contacted to explain the transfer process and freedom of choice options.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    17 views1 page

    Member Request To Transfer

    Uploaded by

    CrapHammer
    This 3 sentence summary provides the key details about a member's request to transfer their care under the Aged and Disabled Waiver Program: The document is a form for a member to request transferring their case management or homemaker agency, or transferring between the traditional agency model and personal options model. The form collects the member's contact and provider information and the reason for the requested transfer. Upon submitting the form, the member will be contacted to explain the transfer process and freedom of choice options.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    of 1

    Aged and Disabled Waiver Program

    Member Request To Transfer



    September 2011 Page 1 of 1

    MEMBER INFORMATION:

    Last First

    Street Address

    City State Zip Code County

    Date of Birth / / Medicaid Number:

    Phone Number: Service Level:

    Legal Representative
    (if applicable)
    Phone Number:
    Home Cell
    My current providers are:
    Case Management Agency
    Homemaker Agency
    Service preferences:
    Monday Tuesday Wednesday Thursday Friday Saturday Sunday
    Hours per day:

    TRADITIONAL AGENCY TRANSFER
    I wish to transfer from my current provider:
    Case Management Agency

    Homemaker Agency

    PERSONAL OPTIONS TRANSFER

    I wish to transfer from Personal Options to a Traditional Agency Model.

    I wish to transfer from the Traditional Agency Model to Personal Options.

    I want to transfer because

    I understand that I will be contacted by the Bureau of Senior Services to explain the transfer process and my
    freedom of choice options.

    _____________________________________________________ _______________
    Member/Legal Representative Signature Date

    Return form to: Bureau of Senior Services, 105 Maplewood Drive, Fairmont, WV 26554
    Phone: 304-366-8779 ext. 19 Fax: 304-957-0175

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