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DISTRICT OF COLUMBIA DEPARTMENT OF HEALTH CARE FINANCE
Retro Eligibility Attestation Form for Long Term Care Services and Supports
This retro attestation form must be completed (all sections are required)
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What is retro eligibility attestation form?
The retro eligibility attestation form is a document used to confirm eligibility for retroactive benefits or services based on specific criteria.
Who is required to file retro eligibility attestation form?
Individuals or organizations seeking retroactive eligibility for benefits or services are required to file the retro eligibility attestation form.
How to fill out retro eligibility attestation form?
To fill out the retro eligibility attestation form, one must provide accurate personal information, specify the requested retroactive period, and sign the document to attest the information is true and correct.
What is the purpose of retro eligibility attestation form?
The purpose of the retro eligibility attestation form is to formally request recognition of eligibility for benefits or services that were due in the past but not claimed at that time.
What information must be reported on retro eligibility attestation form?
The form typically requires personal identification details, the dates for which retroactive benefits are being claimed, and any relevant supporting documentation.
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