WEST VIRGINIA MR/DD WAIVER PROGRAM - Mainstream …
WEST VIRGINIA I/DD WAIVER
APPLICATION
|Applicant Information |
|First Name, MI, Last Name | |Date of Birth | |
|Mailing Address | |
|Physical Address | |
|Phone Number | |Social Security Number | |
|Medicaid Number (if applicable) | |Gender | Male Female |
|Email Address (if applicable) | |County of Residence |State of Residence |
|Legal Representative Information |
|N/A if member is own representative |Parent/relative |Non-relative |DHHR County |
|First Name, MI, Last Name | |Phone Number | |
|Mailing Address | |
|Email Address (if applicable) | |
|Other Representative Information |
|Medical Power of Attorney |Non-legal Representative |Payee | Other____________ |
|First Name, MI, Last Name | |Relationship to Applicant | |
|Address | |
|Phone Number | |Email Address (if applicable) | |
|Applicant/Legal Representative Signature |
|I certify the above information is accurate and complete to the best of my knowledge. I understand the information provided in this document will be treated |
|confidentially. |
| |
|________________________________________________________________________________ |
|Printed Name of Applicant or Legal Representative Date |
| |
|________________________________________________________________________________ |
|Signature of Applicant or Legal Representative Date |
|Form Submission |
|Fax, email or mail I/DD-1 to: APS Healthcare, Inc.-WV 100 Capitol Street, Suite 600 Charleston, WV 25301 Fax#: (866)521-6882 Email: |
|wviddwaiver@ |
|If you have not heard back from APS Healthcare within 5 business days, |
|please call toll free 866-385-8920 |
|DO NOT WRITE BELOW THIS LINE |
|Received by the Administrative Service Organization: |
| |
|_________________________________________________________________________________ |
|Signature of ASO Representative Receiving Form Date |
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