Form 2053-B/Form 2053-BS
Health Plan Selection
This form provides a means for the STAR+PLUS Waiver (SPW) applicant to inform the Department of Aging and Disability Services of the applicant's health maintenance organization (HMO) choice.
When to Prepare
Prepare this form and send with Form 2053-A or Form 2053-AS, STAR+PLUS Release Letter.
Number of Copies/Transmittal
Prepare one copy for the individual and retain the original in the case record.
The case manager keeps all originals in the consumer's case record for five years after services are terminated.