PURPOSE

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.

PROCEDURE

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.

Form Retention

The case manager keeps all originals in the consumer's case record for five years after services are terminated.

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