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Medicaid Freedom of Choice (FOC) List For Waiver Services PROVIDER REQUEST Please Check One:New FOC RequestUpdate existing FOC informationNotification of Agency Closure or Service Termination: Enter
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How to fill out notification of agency closure

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How to fill out notification of agency closure

01
Step 1: Begin by providing the name and address of the agency that is closing.
02
Step 2: Specify the date of closure and the reason for the closure.
03
Step 3: Include a list of all clients or stakeholders who will be directly affected by the closure.
04
Step 4: Mention any alternative arrangements or contact information for the affected parties to consider.
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Step 5: Sign and date the notification, including contact information for further inquiries.
06
Step 6: Distribute the completed notification to all relevant parties.

Who needs notification of agency closure?

01
Notification of agency closure is needed by all clients, stakeholders, employees, and any other individuals or organizations that have a vested interest in the agency's operations or services.

What is Notification of Agency Closure or Service Termination:Enter Effective Date: Form?

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The notification of agency closure is a formal notice informing relevant authorities and stakeholders that an agency will be closing down.
The agency owner or authorized representative is required to file the notification of agency closure.
The notification of agency closure can be filled out online or in paper form, following the instructions provided by the relevant authorities.
The purpose of the notification of agency closure is to inform authorities, employees, clients, and stakeholders about the imminent closure of the agency.
The notification of agency closure typically includes details such as the reason for closure, anticipated date of closure, plans for employee or client transition, and contact information for inquiries.
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