Get the free FM CRCF-01 (June 2014) - Optional State Supplementation

South Carolina Department of Health and Human Services OSS Slot Reservation Request Notice of Admission, Authorization, & Change of Status for Community Residential Care Facility HHS FORM CRCF-01

Form CRCF-01 will be used when: The client is a community resident; An individual, household, or family client is being evaluated at the center; and The client is eligible for Community Residential Care Facility services. The Medicaid reimbursement for Provider Services must be sent to the client's health insurance company for determination of eligibility. If a client is receiving Provider services, no Medicare or private Insurance reimbursement has been made to the center for the Provider services. The form is then completed and submitted to the HHS OSS coordinator. State Medicaid OSS Slot Application The State Medicaid OSS application must include the following information for each eligible applicant (who is also applying for Medicaid): The full name, date of birth, social security number/Social Security Number Card, and date of service The applicant's Medicaid eligibility (permanent and interim) The address of residence The date of application submission to the HHS OSS Coordinator The completed Medicaid OSS registration form for the applicant (for permanent or interim status) All supporting documentation (certified copies of Medicaid application and state/provider verification, if any) If the applicant is applying for permanent status from an outside source, the information should include: State of residence The name of each Medicaid plan that an applicant has been approved for (if any), DHS OSS Coordinator contact information The date of application submission to HHS OSS This form is only used if the individual/s applying for Medicaid (regardless of their temporary and permanent status) are identified as high income individuals. If the individual/s are identified as low to moderate income populations, they are not eligible for OSS services as they do not qualify for a State Medicaid OSS registration. The State OSS Coordinator will not accept this form for all Medicaid applications. In most cases, this form alone will not be used to determine eligibility for Medicaid coverage or payment. If the individual/s submitting this form have a Medicaid registration number, this form will provide the address of the Medicaid facility and the Medicaid services to be provided to the applicant on a short time basis. In these situations this form may be used in lieu of the additional forms submitted. Forms for OSS Registration A copy of all certificates required for Medicaid eligibility must be completed and filed with the individual/s submitting a Medicaid registration application.

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The fm crcf-01 june is a form used for reporting financial information to a regulatory body.

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