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1768 Forms

The Purpose of 1768 forms is to communicate participant’s eligibility changes with the waiver to PA Health & Wellness and the County Assistance Office (CAO)

The 1768 Form needs to be completed for the following scenarios:

  • Participant Change of Address (within PA)
  • Participant Admission to a Long Term Care (LTC) Facility
  • Participant’s Death
  • Other Withdrawal from the Waiver (including moving out of state)

How to complete

  1. Fill out Demographic info on page 1
  2. Fill out the appropriate sections on pages 2-3 based on the scenarios for the form
  3. Upload/Submit to all necessary parties:
    • Function Portal
    • Envolve
    • The CAO

Completing the 1768 Form

Page 1 – Demographic Information

Page 1 is filled out with relevant information regarding the participant and SC.

Department of Human Services (DHS) Office Information

Put in the CAO that the participant reports to, which would be the one the participant lives closest to!

  1. Identify the county the participant lives in (stated in the Info tab of Function Portal)
  2. Look up the list of CAOs Here
    • If there are multiple districts in the county, find out which one is closest to the participant’s address
  3. Put in the CAO county and District (if applicable)
example of completed section

Applicant/Recipient Identification (RID) Information

Put in the following information:

  • Participant’s name (last, first)
  • Participant’s phone number
  • Participant’s SSN
  • Participant’s DOB
  • Participant’s Address
  • Participant’s Recipient ID*

The Recipient ID is put into the MA 10-digit (individual) number

Do NOT check the box of Individual is a new HCBS applicant
Do NOT put in anything for the MA 9-digit record number

Current HCBS/MA RID Information

Select the box for Individual is a current HCBS/MA recipient

Select whether you are submitting a Change such as a Change in address or a Termination for the other scenarios

PA 1768 Originator

Select the box for PA 1768 Form is being submitted by one of the following:

Select the box Service Coordinator (SC)

Representative Information

If you were notified of the event requiring the 1768 form by someone other than the participant, then put in their information here. If not, leave it blank

SC Information

Put in the following information:

  • SC Contact person – your name
  • Telephone Number – Amcord’s main #
    • 215-677-2007
  • Fax number – Amcord’s fax
    • 215-698-6153
  • Email – Your Amcord email
  • SC Name and Address – Amcord’s name and address
    • Amcord Care, Inc. 2600 Philmont Avenue, Ste. 203, Huntington Valley PA 19006

Comments

Put in a description of the event’s that occurred in the Comments section. Be as detailed/descriptive as possible.


Page 2-3 based on scenarios

These pages are filled out differently based on why you are completing the 1768 form. Each scenario and required sections are described below.

Part I is never completed. Always leave this part blank.

Participant change of address (within PA)

Complete the Change of Address section on Page 3.

This section is completed prior to a participant moving to a new address OR if they have already moved and you need to update PHW and/or the CAO about the new address.

Enter the following information:

  • Select whether the participant is moving within the same county they already live in, or if they are moving to a new county
    • If they are moving to a new county, enter in the name of the new county.
  • Date the participant has or will move
  • New/updated address
  • Participant’s telephone number
  • Select if the participant’s services are continuing at this new address or not
    • If services are being terminated, put in the date services are being terminated
Participant Admission to a Long Term Care (LTC) Facility

Complete the HCBS Recipient Admitted to LTC Facility section on Page 2

This section is completed when the participant is being admitted to a Long Term Care facility, such as a Nursing Home.

Do NOT complete this for Respite Care

Enter the following information:

  • Check off the “Individual was admitted to a LTC…” box
  • Name of the Facility they are being admitted to
  • Address of the Facility they are being admitted to
  • Add in date the participant has been or will be admitted to the facility
Participant’s Death

Complete the Information Regarding Death of HCBS Recipient section on page 3

This section is completed after being notified of a participant’s death

Check off the Deceased box and put in the date of the participant’s death

Details about how the participant passed can be put into the Comments section

Other Withdrawal from the Waiver

Complete Program Withdrawal Information, Termination of HCBS Program, and Comments

Check off the Individual voluntarily withdrew and HCBS terminated boxes

Put in the Date of Withdrawal/Termination

Put in the reason of terminating the program

Details about the participant’s reasoning for terminating the waiver in the Comments section


Uploading the 1768 Form

Function Portal

Upload the 1769 form with a new Documentation Upload session. Include a description of the reason for the 1768 form in the comments section.

Envolve

Document Category: Long Term Services & Supports

Document Type: Medical Records

Upload File Name: 1768_Ptp Last name_Ptp first initial_Ptp ID#_Date

Note: If you are completing the 1768 form due to Member Death, you MUST also complete a Member Death note in Envolve

Fax to CAO

Fax to the CAO via RingCentral (go to RingCentral.com or use the Ringcentral app if you have that downloaded)

Select the + in the top right hand corner or the phone icon to make a new fax

Once you started a new fax, enter the fax # number of the CAO you are sending this to (contact info can be found here again) and attach the 1768 form that you are sending.

Once you have completed the form you MUST email your supervisor with details and a copy of the 1768 form

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