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LDSS3174 Statewide (Rev. 07/23) CENTER/ OFFICEINTERVIEW DATEUNIT IDWORKER IDCASE TYPECASE NUMBERCASE NAMEDISTRICTEFFECTIVE DATEDATEELIGIBILITY APPROVED BY (SUPERVISOR):LANGNUMBER REUSE INDICATORDISPOSITIONRECERTIFICATION
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How to fill out ldss-3174 statewide dd rev
01
Obtain a copy of LDSS-3174 Statewide DD Rev form.
02
Fill out the top section with personal information such as name, address, and contact details.
03
Provide information about the individual receiving services such as Medicaid ID, date of birth, and diagnosis.
04
Fill out the rest of the form as required, providing details about the services being requested and any additional information that may be relevant.
05
Review the completed form for accuracy and make any necessary corrections before submitting it to the appropriate agency.
Who needs ldss-3174 statewide dd rev?
01
Individuals or their caregivers who are applying for services through the Medicaid program in the state.
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What is ldss-3174 statewide dd rev?
The LDSS-3174 Statewide DD Rev is a form used in New York State for reporting and documenting authorized expenses and revenues related to the delivery of services for individuals with developmental disabilities.
Who is required to file ldss-3174 statewide dd rev?
Organizations and agencies that provide services to individuals with developmental disabilities and receive funding or reimbursements from the state are required to file the LDSS-3174.
How to fill out ldss-3174 statewide dd rev?
To fill out the LDSS-3174, organizations must provide specific information regarding their revenues, expenses, and other financial data related to the services provided. Detailed instructions are included in the form guidelines.
What is the purpose of ldss-3174 statewide dd rev?
The purpose of the LDSS-3174 is to ensure accountability and transparency in the financial operations of agencies providing services to individuals with developmental disabilities, allowing for proper oversight and allocation of state funds.
What information must be reported on ldss-3174 statewide dd rev?
The form requires reporting on revenues, expenditures, funding sources, and specific line-item details about the services provided to individuals with developmental disabilities.
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