4.00 Appendix 11 Contact Form Instructions
Home and Community Based Services Manual
4.00 Appendix 11 Contact Form Instructions
The Contact Form provides the current or potential participant and/or their authorized representative, (e.g., guardian, or someone with a signed Authorization for Disclosure of Consumer Medical/Health Information that is in effect) with written notification of the Division of Senior and Disabilities (DSDS) attempts to reach the participant and/or their authorized representative by phone or in person.
Instructions
Enter the current or potential participant’s name, DCN, address, and last known phone number, including an extension number as appropriate.
• For current or potential participants that have an authorized representative, enter the authorized representative’s contact information.
Enter the appropriate “Communication: Reason for Contact” from Appendix 12.
• It may be appropriate in certain cases to enter more than one category from Appendix 12.
DSDS staff completing the form shall enter their name, email address, office phone number, including an extension number as appropriate and mailing address.
Enter the date the notice is mailed.
Distribution
Upon completion, the original Contact Form shall be mailed to the current or potential participant and/or their authorized representative. A copy is also maintained in the participant’s electronic case record.