DHS-4689A-ENG   3-23   1.0.10

DISABILITY SERVICES DIVISION

Screening Deletion Request

Information for person who receives services

Waiver/program type

Indicate the most recent screening document that should be kept. If you are deleting the only or all the screening documents in MMIS, select “delete all”


Indicate what the waiver or AC eligibility span should look like after the screening has been deleted, but before the case is rebuilt (check one)

NOTE: The deletion process can remove waiver/program eligibility spans but will not extend waiver/program eligibility end dates.

Reason for deletion request (check all that apply)


NOTE: Provide additional information to support your request on a second page if needed.The text will appear here

Documentation

Timeline

DHS will make every effort to process screening document deletion requests on a weekly basis