Joe Manchin III



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| |STATE OF WEST VIRGINIA | |

| |DEPARTMENT OF HEALTH AND HUMAN RESOURCES | |

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|Bill J. Crouch | | Cynthia E. Beane |

|Cabinet Secretary | |Commissioner |

Kepro

CSEDW Program

1007 Bullitt Street, Suite 200

Charleston, WV 25301

Telephone: 1-844-304-7107 Fax: 1-866-473-2354

To: APPLICANT NAME

APPLICANT NAME

APPLICANT ADDRESS 1

APPLICANT ADDRESS 2

From: CSEDW Program Manager

WV Bureau for Medical Services

Date: DATE

Re: Initial Application Closure: Financial Eligibility Not Established

Our records indicate that you do not meet the financial eligibility requirements to be able to receive/enter the CSED waiver program.

This letter is to inform you that because you do not meet financial eligibility requirements, we have closed your application for consideration into the WV CSED Waiver Program. If you wish to pursue program consideration, you will need to reapply by completing another WV-BMS-CSED-1 Application Form and submitting it to KEPRO along with proof of financial eligibility from the Department of Health and Human Resources (DHHR).

Questions regarding the information contained in this letter may be directed to KEPRO by calling 1-844-304-7107 or via email at: wvcsedw@. Questions can also be mailed to: KEPRO 1007 Bullitt Street, Suite 200, Charleston, WV 25301.

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Bureau for Medical Services

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