Form 2067, Case Information
Effective Date: 12/2012
To request and share case information not available through data inquiry.
Form 2067 is used by Department of Aging and Disability Services (DADS) staff.
When to Prepare
Prepare Form 2067 when staff:
- request or share information about case record transfers.
- request or share other case information. Example: DADS staff notify provider staff of a charge in an individual's circumstances.
- and/or contractors in different program areas share information or request or refer services. Examples:
- DADS staff and Medicaid for the Elderly and People with Disabilities (MEPD) staff report or request information about an individual;
- DADS staff and service providers communicate about referrals, negotiated start dates and changes in service plans;
- DADS staff share information with applicants/individuals regarding the Medicaid Estate Recovery Program (MERP); or
- DADS staff share information with applicants/individuals regarding other long-term services and supports (LTSS).
Number of Copies
Complete an original and one copy.
Send the original to staff whom you are providing information. When responding to a request for information, return the original to staff who requested the information. Place the copy in a suspense file or case folder as appropriate.
Retain this form according to the terms in the applicable DADS program handbook.
Enter names and addresses of the staff receiving and sending Form 2067. Enter the case name, address, area code and telephone number. Enter category or kind of assistance and the case or other identifying number.
Check the appropriate blocks to show what kind of information is being shared or requested or which services are requested.
Enter a description of the information being shared or requested. Use the back of the form if needed.
Enter the initiating staff's signature, date, area code and telephone number.
Enter a description of the information; use the back of the form if needed. Enter the responding staff's signature, date, area code and telephone number. Enter the name and addresses of the people receiving and sending the response.