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northeast iowa mental health & disabilities services ... - Fayette County

northeast iowa mental health & disabilities services ... - Fayette County

Form B: NOTICE OF

Form B: NOTICE OF ELIGIBILITY NORTHEAST IOWA COUNTIES CPC/COMMUNITIY SERVICES NOTICE OF ELIGIBILITY Application Date: Date Received by CPC Office: ____________________________ Last Name: First Name: __________________________ MI: __________ Unique ID#:__________________________ Date Contacted: ______________________ Disability Group-DX Type: MI CMI MR DD SA OTHER Legal Settlement: _______________________________ (Attach Legal Settlement Checklist if needed) Determination: Accepted Denied (see comments below) Pending (see comments below) Funding Secured: YES NO Arranged: _____________________________________________ Date of Decision: _________________________ Date NOD sent: _______________________ If denied, check applicable reason: Over income guidelines Other county of legal settlement _______________ Does not meet diagnostic criteria Applicant desires to stop process Does Not meet service plan criteria Other____________________________________ Does not meet plan criteria Other referrals given (DHS, TCM, etc.): ______________________________________________________ County Co-payment amount/terms (if applicable): ______________________________________________ Comments: ______________________________________________________________________________ CPC staff making determination & Date: ___________________________________________________ 43

Form C: SERVICE FUNDING REQUEST/NOTICE OF DECISION NORTHEAST IOWA COUNTIES CPC / COMMUNITY SERVICES FUNDING REQUEST/NOTICE OF DECISION TO: Name: _________________________________________________ Client SS#: ###-## - _ _ _ _ Address: _________________________________________________ State ID _______________ _________________________________________________ DOB: _______________ Please identify the services being requested in the boxes below, and we will return this form to you with our decision in the boxes on the right hand side. We will also send copies of this form with our decision to the providers you identified. SERVICES BEING REQUESTED: CPC USE ONLY (1) (2) (3) (4) (5) Agency Name Service Requested Number of Units Unit Cost 44 Expected Start Date Expected End Date Approved Approved pending availability of funds _____________________________________ ________________________ ___________________ __________________ Name of the person completing the form Agency Phone Fax Applicant’s Signature: __________________________________________________ Date: _______________________ If your services were denied, the process to appeal this decision is on the back of this page. If approved, Authorization start date:_______________________ Authorization end date:________________________ Denied (Appeal process on back) Conditions for approval/Other comment: ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ The client has legal settlement in ________________________ County and residency in _____________________________ County. The service decision is based on the County Management Plan of Residence. Please bill __________________________ County the county of legal settlement for payment of the approved services. Central Point of Coordination Administrator Signature Residency County: ________________________________Date _________ cc: _______County of Legal Settlement ______ Listed Providers ___________________________ County agrees with the legal settlement determination made by the county of residence. Legal settlement County CPC Signature:_____________________________________________Date______________________ Copies to be returned by the Legal Settlement County: ________County of Residence _________ Listed Providers

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