Waiver Services Provider Certification

WAIVER SERVICES PROVIDER CHOICE CERTIFICATION

TO THE CONSUMER: Please complete all sections of this form and attach the appropriate initial page(s) from the service provider choice list.
Support Coordinator's Email*
example@example.com
Participant's initials*
Recipients Name*
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone Number*
Social Security Number*
Medicaid Number*
I confirm that I have been advised of Medicaid Waiver service providers available within my region and have had the opportunity to select which provider I wish to utilize for the services indicated on the attached sheet(s
Signature of Recipient/Legal Guardian*

Clear
Date*

MonthDayYear
Date
Should be Empty: