Form Msc1 Appl – Fill Out and Use This PDF

Individual Application for Participation in Medicaid Service Coordination

Section I. Individual Information

Name:	Last	First		MI	TABS ID# (if known)	Social Security Number:
Address:		Street			Date of Birth:	Medicaid Number:
City:			State:	ZIP Code:	Phone:	DDSO:

Section II. MSC Vendor/DDSO Information

Vendor/DDSO Name:

Vendor address:

City:		State:	ZIP Code:
TABS Program Code:

Section III. Individual Signature

I am requesting participation in MSC effective	(date)
I have chosen the MSC Vendor/DDSO identified above to provide the MSC services I want and need.
Individual’s Signature			Phone:	Date:
Family Member or Advocate’s Signature (if appropriate)
Phone:		Date:
Family Member of Advocate’s Address (if different from individual):

Section IV. Vendor Signatures

The individual identified above has indicated a need for an MSC service coordinator. To the best of my knowledge, this individual meets all of the eligibility criteria necessary for participation in MSC.

MSC Vendor/DDSO Contact’s Name (print)

MSC Vendor/DDSO Contact’s Signature

Phone Number:	Date:

Section V. To be completed by the DDSO MSC Coordinator

Date Application Received:	Request for MSC	APPROVED for TABS processing
	Request for MSC	WITHDRAWN by individual
	Request for MSC DENIED
Reason for Denial:

Individual is not enrolled in Medicaid.

Individual does not have a diagnosis of a developmental disability.

Individual is permanently enrolled in another comprehensive Medicaid long term care service coordination program. Individual currently resides in an ICF/MR, ICF/DD or in another Medicaid facility that provides service coordination. Individual did not respond to request for information.

Individual does not meet the need for ongoing and comprehensive service coordination.

Signature of DDSO MSC Coordinator:

Date:

REVISED 4/27/2011

Instructions for Completion of the

Individual Application for Participation in Medicaid Service Coordination (MSC1-APPL)

Please clearly print (or type) all information

Section I INDIVIDUAL INFORMATION: This section should be completed by the MSC vendor, or DDSO for state delivered MSC, selected by the individual.

Section II MSC VENDOR/DDSO INFORMATION: This section should be completed by MSC vendor, or DDSO for state delivered MSC, selected by the Individual.

Section III The individual and MSC vendor, or DDSO for state delivered MSC, must agree upon an effective date. The effective date should be the date on which the individual needs MSC to begin, if all eligibility factors are met.

This section must be signed by the individual, or individual’s family or advocate, if appropriate. The signatures verify that the individual has chosen the agency identified above to provide him or her with MSC.

The family member or advocate’s address must be included if different from the individual’s address.

Section IV This section is signed by a staff person representing the MSC vendor, or the DDSO for state delivered MSC. The signature verifies that the individual has indicated a need for MSC and, in the best judgment of the vendor or DDSO, the individual meets all of the eligibility criteria required to receive MSC.

Once Sections I, II, III, and IV have been completed, this form should be sent to the DDSO’s MSC Coordinator.

Section V This section is to be completed by the DDSO’s MSC Coordinator. Please refer to MSC Manual section, INDIVIDUAL ENROLLMENT IN MSC, for additional information.

Date Application Request Received:	DDSO date stamps application upon receipt.
Request APPROVED for TABS Processing:	If application form is complete and DD diagnosis verified:
	DDSO checks this item, signs and dates this section,
	and then forwards application to data entry person for
	TABS processing and eligibility determination.

Reason for MSC DENIED:	When it has been determined that the individual will not
	meet the MSC eligibility criteria, or the individual hasn’t
	send in the required documents within the allotted time
	frames: DDSO checks this item, checks the specific
	reason for denial, signs and dates this section, and
	forwards a copy to the data entry person so the
	individual can be removed from pended file.

Data entry person initials and dates the form after completing the data entry.

The form is then returned to the DDSO’s MSC coordinator.

REVISED 4/27/2011