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Medicaid Freedom of Choice (FOC) List For Waiver Services PROVIDER REQUEST Please Check One: New FOC Request Update existing FOC information Notification of Agency Closure or Service Termination:
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What is dom of choice form?
The DOM of Choice form is a legal document that allows an individual to designate a durable power of attorney for medical decisions in case they become unable to make those decisions themselves.
Who is required to file dom of choice form?
Any individual who wants to appoint a durable power of attorney for medical decisions must file the DOM of Choice form.
How to fill out dom of choice form?
To fill out the DOM of Choice form, you need to provide your personal information, including your name, address, and contact details. You also need to designate the person you want to appoint as your durable power of attorney and provide their information as well. Additionally, you may need to sign and date the form.
What is the purpose of dom of choice form?
The purpose of the DOM of Choice form is to legally appoint and give authority to a durable power of attorney to make medical decisions on an individual's behalf if they become unable to do so themselves.
What information must be reported on dom of choice form?
The DOM of Choice form requires the reporting of personal information such as the individual's name, address, and contact details. Additionally, it requires the reporting of the chosen durable power of attorney's name, address, and contact details.
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