Transcription of Intake and Referral - Wa
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Intake and Referral - Wa
Intake AND REFFERAL DSHS 10-570 (REV. 08/2017) Page 1 of 2 HOME AND COMMUNITY SERVICES Intake and Referral Section 1. Referent Information 1. FULL NAME OF AGENCY OR FACILITY 2. TYPE OF FACILITY 3. REFERENT S NAME 4. REFERENT S RELATIONSHIP TO APPLICANT 5. PHONE NUMBER ( ) EXT. 6. DATE 7. REFERENT S ZIP CODE Section 2. Applicant Information 1. APPPLICANT S NAME: LAST, FIRST, MI 2. GENDER Male Female 3. BIRTH DATE 4. SOCIAL SECURITY NUMBER 5. APPLICANT S HOME ADDRESS CITY STATE ZIP CODE 6. APPLICANT S MAILING ADDRESS (IF DIFFERENT) CITY STATE ZIP CODE 7. APPLICANT S PRIMARY PHONE NUMBER ( ) 8. APPLICANT S EMAIL ADDRESS 9. AUTHORIZED REPRESENTATIVE S NAME RELATIONSHIP TO APPLICANT TELEPHONE NUMBER: ( ) 10.
a) Washington Apple Health is the WA Medicaid program. b) MAGI refers to Adults on Medicaid through expansion of the Affordable Care Act. c) ACES client ID number can be found in a ProviderOne benefit inquiry and is also known as the DSHS number.
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