Effective Date
Instructions
Updated: 2-2008
Purpose
To obtain the correct information (units/dollars) from the transferring individual Directed Services Agency (CDSA) that is to be reserved by the transferring program provider, current program provider or transferring CDSA. This will enable the Local Authority (LA) service coordinator/program provider case manager to complete the transfer data entry screens in the Client Assignment and Registration (CARE) system.
Procedure
Form is initiated by the transferring CDSA once the individual's transfer effective date has been established.
Detailed Instructions
The CDSA will ensure that the following information is completed properly.
Individual's Information
The CDSA will complete each of these sections:
Name — Enter the name of the employee/individual who is transferring.
Medicaid No. — Enter the Medicaid number of the employer/individual who is transferring.
CARE ID No. — Enter the CARE identification number of the employer/individual who is transferring.
Transferring Individual Directed Services Agency Information
CDSA Legal Entity Name — Enter the legal name of the transferring CDSA.
Telephone No. — Enter the telephone number of the transferring CDSA.
CDSA Contact Name — Enter the name of the transferring CDSA's representative.
Fax No. — Enter the fax number of the transferring CDSA's representative.
CDSA Component Code/Local Case No. — Enter the component code of the transferring CDSA, as well as the employer/individual local case number.
Contract No. — Enter the vendor number of the CDSA from which the employer/individual is transferring.
Service County Code/Name — Enter the county code/name of the county in which the employer/individual currently receives services.
Transfer Effective Date — Enter the mutually agreed upon transfer effective date.
Dollar Amounts for Services to be Transferred
Enter the dollar amounts of services (for each service with CDS service delivery option) that are to be transferred to the receiving program provider or CDSA.
Number of Service Units to be Transferred
Enter the units of service (for each service with CDS service delivery option) that are to be transferred to the receiving program provider or CDSA.
Printed Name — Transferring CDSA Representative — Print the name of the CDSA representative who signed the form.
Signature — Transferring CDSA Representative — The CDSA representative who verifies that the information entered on the form is correct signs the form.
Date — Enter the date the CDSA representative signed the form.
Printed Name – Employer/Guardian — Print the name of the employer/guardian.
Signature – Employer/Guardian — The employer/guardian who verifies that the information entered on the form is correct signs the form.
Date — Enter the date the employer/guardian signed the form.