1768 Session
If the participant is refusing all services/voluntarily withdrawing from the waiver you must FIRST notify your SCS/AVP. You will NOT do the 1768 session until AFTER a task has been received 20 days later.
Tips for Completing the 1768 Form
Applicant/Recipient Identification (RID) Information
Select Change when you are reporting a change of information to the CAO, such as a Change in address. Select Termination for the other scenarios such as death or admitted to Long Term Nursing Facility.
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
Comments
Put in a description of the event’s that occurred in the Comments section. Be as detailed/descriptive as possible.
Participant change of address (within PA)
This section is completed prior to a participant moving to a new address OR if they have already moved and updated address needs to be sent to CAO.
Participant Admission to a Long Term Care (LTC) Facility
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 Short Term Rehab stays or Respite Care
Participant’s Death
This section is completed after being notified of a participant’s death
Details about how the participant passed can be put into the Comments section
If the 1768 is due to Member Death, you MUST also complete a Member Death session in FP
Other Withdrawal from the Waiver
Complete Program Withdrawal Information, Termination of HCBS Program, and Comments
Add details about the participant’s reasoning for terminating the waiver 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
Fax to CAO
Do NOT fax to CAO until you are told to do so by a Supervisor or through a task.
Fax to the CAO via RingCentral (go to RingCentral.com or use the Ringcentral app if you have that downloaded).
Once the 1768 Session is completed, SC Supervisor MUST be emailed that the session was submitted