Effective Date
Instructions
Updated: 1/2026
Purpose
A local intellectual and developmental disability authority (LIDDA) must complete Form 1040 to accompany a packet of materials the LIDDA sends to a Medicaid managed care organization (MCO). The packet includes documents related to a person’s eligibility or reassessment for Community First Choice (CFC) services provided through a Medicaid MCO.
When to Prepare
The LIDDA completes Form 1040 when submitting CFC non-waiver eligibility or reassessment packets to MCOs.
Submittal
The LIDDA submits this form and the CFC packet to the appropriate CFC MCO folder on the LIDDA Connect SharePoint site.
Detailed Instructions
Section 1 – Person’s Information
Date – Enter the current date.
Last Name – Enter the person’s last name.
First Name – Enter the person’s first name.
Medicaid ID – Enter the person’s Medicaid number.
CARE ID – Enter the person’s Client Assignment and Registration (CARE) System identification number.
Area Code and Phone No. – Enter the person’s area code and phone number.
Alternate Area Code and Phone No. – Enter the person’s alternate area code and phone number.
Mailing Address – Enter the person’s mailing address.
Legally Authorized Representative (LAR) Name if applicable – Enter the name of the person’s LAR if applicable. Enter NA for not applicable if there is no LAR.
LAR Area Code and Phone No. – Enter the area code and phone number of the LAR. Enter NA if there is no LAR.
LAR Alternate Area Code and Phone No. – Enter the alternate area code and phone number of the LAR. Enter NA if there is no LAR.
LAR Mailing Address – Enter the LAR’s mailing address. Enter NA if there is no LAR.
Section 2 – LIDDA Information
Name – Enter the name of the LIDDA submitting the form.
Component Code – Enter the LIDDA’s three-digit component code.
Contact Name – Enter the name of the LIDDA staff to be contacted about this form.
Contact Area Code and Phone No. – Enter the area code and phone number of the staff identified as the LIDDA contact.
Contact Area Code and Fax No. – Enter the area code and fax number of the staff identified as the LIDDA contact.
Contact Email Address – Enter the email of the staff identified as the LIDDA contact.
Name of Alternate Contact – Enter the name of an alternate LIDDA staff to be contacted about this form.
Alternate Contact Phone No. and Area Code – Enter the area code and phone number of the staff identified as the alternate LIDDA contact.
Section 3 – Managed Care Organization (MCO) Information
Name – Enter the name of the person’s MCO.
Component Code – Enter the MCO’s three-digit component code.
Contact Email Address – Enter the MCO contact’s email address.
Contact Name – Enter the name of the MCO staff to be contacted about this form.
Contact Area Code and Phone No. – Enter the area code and phone number of the staff identified as the MCO contact.
Contact Area Code and Fax No. – Enter the area code and fax number of the staff identified as the MCO contact.
Name of Alternate MCO Contact – Enter the name of an alternate MCO staff to be contacted about this form.
Alternate MCO Contact Area Code and Phone No. – Enter the area code and phone number of the staff identified as the alternate MCO contact.
CFC Packet Checklist for MCO Submission – Check the type of packet being sent to the MCO: initial, renewal or revision. Select every form included with the packet submission.
LIDDA Staff Completes the Section Below
Send list of providers for the checked services to:
Name – Enter the name of the person to receive services.
By Email – Select this option and enter the person’s email if they choose to receive the provider list by email.
By Mail – Select this option and enter the person’s full address if they choose to receive the provider list by mail.
Check the box for CFC Personal Assistance Services, CFC Habilitation, CFC Emergency Response Services or CFC Financial Management Services Agency.
Check Yes or No to indicate if the person or LAR wishes to change providers.
Joint meeting is scheduled for:
Date – Enter the date the joint meeting is scheduled.
Time – Enter the time the joint meeting is scheduled.
Meeting Location – Enter the address for the scheduled meeting.