Form 2439, Selection Acknowledgement

Effective Date: 3/2015

Availability

PDF: 2439.pdf

Instructions

Updated: 3/2015

Purpose

To give the individual released from the Medically Dependent Children Program (MDCP) interest list the choice to express interest in or decline an application for MDCP services.

Procedure

When to Prepare

DADS staff transmit the form to individuals/families with children whose names have been released from the MDCP interest list. This form should be completed and returned to the case manager before initiating a home visit.

Number of Copies

Original.

Transmittal

This form is included in the enrollment packet sent to the individual released from the MDCP interest list. The individual/family complete and return this form to the case manager.

Form Retention

The case manager must retain this form in the applicant/individual's case file. If the individual declines to apply for MDCP services, the form is filed in the closed case file until the end of the fiscal year plus five years.

Detailed Instructions

Individual's Name — Enter the individual's name.

Parent's Name — Enter the individual's parent's name.

Mailing Address — Enter the individual's address.

Area Code and Telephone Number — Enter the individual's area code and telephone number.

This section is completed by the individual/family:

Box 1 — The individual is interested in applying for MDCP services.

Box 2 — The individual is no longer interested in MDCP services.

Box 3 — The individual is not interested in MDCP services at this time, but would like to be placed back at the bottom of the MDCP interest list with a new release date.

This form must be completed ... — Enter the date that is 30 calendar days from the date on Form 2440, Release from the MDCP Interest List, or Form 2441, Release from the MDCP/CLASS Program Interest Lists.

Signature Line — The individual/parent/guardian must sign and date the form upon completion.

The form must be returned to the case manager no later than the date provided.

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