NEW CLIENT CHECKLIST - Alaska Care Coordination Network
NEW CLIENT INTAKE
o Name: ________________________________________ DOB: ____________
o Referral from ___________________________________ on _____________
o Medicaid status?
o POA or Guardian?
o Medical condition:
o Address/Directions:
NEW CLIENT CHECKLIST
o Review waiver program handout and give business card
o Explain timeline/process
o Review/sign Appointment of CC form
o Do application form/gather information
o Review/sign Release of Information forms (MD, hospital, DPA, etc.)
o Review/sign Recipient Rights & Responsibilities form
o Review HIPAA form
o Review Fair Hearing information
o Get Medicaid number/dates or assist in completing DPA application (med 4) and request screening coupon from DPA if necessary
o Get copy of POA or guardianship paperwork if applicable
o DME needs:
o TO DO:
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