DHS-6893K-ENG 1-25 (1.0.4)

COMMUNITY FIRST SERVICES AND SUPPORTS (CFSS)

CFSS Technical Change Request

CFSS service providers complete and submit this form to request a technical change to an existing approved CFSS service authorization (SA) for the person who receives services.

Complete and submit the Referral for Reassessment for CFSS/PCA Services, DHS-6863B (PDF) to the lead agency to request a new authorization or report a change in condition.

For use by CFSS service providers only.

Service agreement

CHANGE/START DATE

END DATE

Person's information

LAST NAME

FIRST NAME

8 Digit MEMBER ID (also known as PMI number)

DATE OF BIRTH

CFSS MODEL

Agency model

Budget model

Person or participant's representative signature

NAME OF PERSON WHO SIGNED RELEASE

DATE OF SIGNATURE

RELATIONSHIP TO MEMBER (if member is their own responsible party, enter self)

As the provider, I have received/maintained the signature of the person or participant's representative requesting this change

Additional information

Provider agency information

PROVIDER NAME

PROVIDER NPI or UMPI

Are you a consolidated provider?

Yes

TAXONOMY CODE

I don't know my taxonomy code (provider type and address required)

PROVIDER TYPE (two digit code)

FULL ADDRESS

YOUR NAME

TITLE

PHONE NUMBER

CFSS Technical Change Request

Service agreement

Request type (request for your agency only)

Personal care services

Consultation service

FMS fee

Failed background study

Goods and services

PERS

Worker training and development

Personal care services

Consultation service

FMS fee

Goods and services

PERS

Worker training and development

Attachments

Duplicate copy of Service Agreement

Report change in participant's representative

Increase

Consultation

Worker training and development

Other

Attachments

Person's information

Person or participant's representative signature

Additional information

Provider agency information