̰̐̓͋ϰ E̟̋̓͗δ̢̋δ̰̌ ϴδ̢͖ϳΦδ̦ ̔̐Eϴ̕ ̊Θϳ͖δ̢

Ǐ̡͋ϳ̢͝ Lϳ̦̰
Ě̢̓̅̅̋δ̰̌ P̢̓Φδ̦̦
̑ϯίί ̎̀̚ϮΡ͘ ϮϮͽͽϩϭ̒

Iξ ξΘ̋ϳ̅͝ ̰̌̓ ϳ̰̌δ̢δ̦̰δΰϫ ̢̓ ̌̓  !ΰΰ ̌Θ̋δ Θ̌ΰ Φ̰̓̌ΘΦ̰ ϳ̌ξ̢̓̋Θ̵̓̌ ̰̓ Ǐ̡͋ϳ̢͝ Lϳ̦̰Ϯ
̟ϰ̓̌δ ΦΘ̅̅ ̢δ̦̟̦̓̌δ ͗ϳ̰ϰϳ̌ ̦δ͖δ̌
 ̰̓̌ΘΦ̰ L!R ͗ϳ̰ϰϳ̌ ̓̌δ Υ̦͋ϳ̌δ̦̦ ΰΘ͝ ̰̓ ̢̟͖̓ϳΰδ ̢̟̓Ϧ̢Θ̋ ϳ̌̈
Υ̦͋ϳ̌δ̦̦ ΰΘ̦͝ϫ ̦δ̌ΰ Letter of
ξ̢̓̋Θ̵̓̌ ΘΥ̰̓͋ ̰ϰδ ̐Eϴ ̊Θϳ͖δ̢Ϯ
WithdrawalϮ

̊ϳ̰ϰϳ̌ ̦δ͖δ̌ Υ̦͋ϳ̌δ̦̦ ΰΘ̦͝ϭ

 ϴδ̌ΰ Denial of Eligibility ̅δ̿δ̢ Θ̌ΰ Fair Hear-

Dδ̋̓Ϧ̢Θ̟ϰϳΦ NO ing Request ξ̢̓̋Ϯ
E̅ϳϦϳΥϳ̅ϳ̰͝ϣ
 P̢͖̓ϳΰδ ̢δξδ̢̢Θ̦̅ ̰̓ ̰̓ϰδ̢ ̦δ̢͖ϳΦδ̦ϫ ϳ̌Φ̅͋ΰϳ̌Ϧ
LMH! ϳ̌ ϳ̌ΰϳ͖ϳΰ͋Θ̅ϱ̦ Φ̰̓͋̌͝ ̓ξ ̢δ̦ϳΰδ̌ΦδϮ
̐Eϴ

̊ϳ̰ϰϳ̌ ̦δ͖δ̌ Υ̦͋ϳ̌δ̦̦ ΰΘ̦͝ϭ

 LϳΦδ̦̌δΰ P̢̓ξδ̦̦ϳ̓̌Θ̅ ̓ξ ̰ϰδ HδΘ̅ϳ̌Ϧ !̢̰̦ ̔LPH!̕ ̋δδ̰̦ ͗ϳ̰ϰ ϳ̌ΰϳ͖ϳΰ͋Θ̅ Θ̌ΰ L!R ̰̓ Φ̟̓̋̅δ̰δ  ϺRR ϴδ̢͖ϳΦδ̦ ΦΘ̌ ΥδϦϳ̌Ϯ ̖Ϯϱ Ϻ! ϰϭϮϮϯϮϮϬ
̰ϰδ ϰϳ̅ΰ Θ̌ΰ !ΰ̓̅δ̦Φδ̰̌ Nδδΰ̦ Θ̌ΰ ϴ̢̰δ̌Ϧ̰ϰ̦ ̔!Nϴ̕ Θ̦̦δ̦̦̋δ̰̌Ϯ Ϯϱ Ϻ! ϰϭϮϮϰ΂ϳ̗
 Ͼ̵̅ϳ͢Θ̵̓̌ MΘ̌ΘϦδ̋δ̰̌ Θ̰͋ϰ̢̓ϳ͢δ̦ ϳ̌ΰϳ͖ϳΰ͋Θ̅ ϳ̰̌̓ LO̊̐EϴϮ  ̢̊Θ̟Θ̢̓͋̌ΰ FΘΦϳ̅ϳ̰Θ̢̰̓ Θ̦̦ϳϦ̌δΰ ͗ϳ̰ϰϳ̌
 ̟̓̋̅δ̰δ ̰ϰδ Clinical Eligibility Determination Form Θ̌ΰ ̰ϰδ Enrollment Packet (except the ̰͗̓ Υ̦͋ϳ̌δ̦̦ ΰΘ̦͝Ϯ
!̫͆ϫ̝̎Ϯ͝Γ̰̎̇ ̎ι ϯί̝͑ϮΡί̡ letter)Ϯ ϰ̟̿ϭ̂̂͗͗͗Ϯΰ̦ϰ̦Ϯ̦̰Θ̰δϮ̰͜Ϯ̦͋̂̋ϰ̦Θ̂͝δ̦̂ ̑ϯίί ̎̀̚ϮΡ͘ ϮͽͽͽϩϮ̒  Fϳ̢̦̰ ξΘΦδ-̰̓-ξΘΦδ ̋δδ̵̌Ϧ ̓ΦΦ̢̦͋ ͗ϳ̰ϰϳ̌
̦δ͖δ̌ Υ̦͋ϳ̌δ̦̦ ΰΘ̦͝Ϯ

̊ϳ̰ϰϳ̌ τ͖δ Υ̦͋ϳ̌δ̦̦ ΰΘ̦͝ϫ δ̰̌δ̢

Φ̅ϳ̌ϳΦΘ̅ δ̅ϳϦϳΥϳ̅ϳ̰͝ ΰ̓Φ͋̋δ̰̌Θ̵̓̌ D̓δ̦ ϳ̌ΰϳ͖ϳΰ͋Θ̅ NO
ϴδδ Ě̢̓̅̅̋δ̰̌ P̢̓Φδ̦̦ ξ̢̓
ϳ̰̌̓ MHϴϮ ϰΘ͖δ MδΰϳΦΘϳΰϣ
Ǐΰϳ͖ϳΰ͋Θ̅ ͗ϳ̰ϰ̰̓͋ MδΰϳΦΘϳΰ

̐Eϴ
Iξ ̌̓ ̢δ̦̟̦̓̌δ ξ̢̓̋ L!R ΘϢδ̢ ̰͗̓
̟ϰ̓̌δ ΦΘ̦̅̅ Θ̌ΰ ̰͗̓ ̅δ̿δ̢̦ ͗ϳ̰ϰϳ̌
ϯ΂ ΦΘ̅δ̌ΰΘ̢ ΰΘ̦͝ϫ ̦δ̌ΰ Letter of ϴδδ Ě̢̓̅̅̋δ̰̌ P̢̓Φδ̦̦ ξ̢̓
WithdrawalϮ Ǐΰϳ͖ϳΰ͋Θ̅ ͗ϳ̰ϰ MδΰϳΦΘϳΰ
 ̰̐̓͋ϰ E̟̋̓͗δ̢̋δ̰̌ ϴδ̢͖ϳΦδ̦ ̔̐Eϴ̕ ̊Θϳ͖δ̢
Ě̢̓̅̅̋δ̰̌ P̢̓Φδ̦̦

Ě̢̓̅̅̋δ̰̌ P̢̓Φδ̦̦ ξ̢̓ Ǐΰϳ͖ϳΰ͋Θ̅

͗ϳ̰ϰ MδΰϳΦΘϳΰ

̊ϳ̰ϰϳ̌ ̦δ͖δ̌ Υ̦͋ϳ̌δ̦̦ ΰΘ̦͝ ̓ξ Φ̅ϳ̌ϳΦΘ̅ δ̅ϳϦϳ̈

̐Eϴ
̊ϳ̰ϰϳ̌ ̰δ̌ Υ̦͋ϳ̌δ̦̦ ΰΘ̦͝ ̓ξ Φ̅ϳ̌ϳΦΘ̅ δ̅ϳϦϳΥϳ̅ϳ̰͝ Θ̰͋ϰ̢̓ϳ͢Θ̵̓̌ϫ
̢̊Θ̟Θ̢̓͋̌ΰ FΘΦϳ̅ϳ̰Θ̢̰̓ϭ
 P̢͖̓ϳΰδ̦ !uthorization of Services ̅δ̿δ̢ ̰̓ L!RϮ
 ̵̓̌̌͋δ̦ ̢̊Θ̟Θ̢̓͋̌ΰ ̢̟̓Φδ̦̦ Θ̌ΰ Φ̟̓̋̅δ̰δ̦ϭ
 Ǐΰϳ͖ϳΰ͋Θ̅ P̅Θ̌ ̓ξ Θ̢δ ̔IP̕Ϭ Θ̌ΰ
 ̢ϳ̦ϳ̦ ϴΘξδ̰͝ P̅Θ̌Ϯ
NO Υϳ̅ϳ̰͝ ΰδ̌ϳΘ̅ϭ
̅ϳ̌ϳΦΘ̅ E̅ϳϦϳΥϳ̅ϳ̰͝
Θ̰͋ϰ̢̓ϳ͢δΰ Υ͝ DϴHϴϣ  ϴδ̌ΰ Denial of Eligibility ̅δ̿δ̢ Θ̌ΰ Fair
Hearing Request ξ̢̓̋Ϯ
 P̢͖̓ϳΰδ ̢δξδ̢̢Θ̦̅ ̰̓ ̰̓ϰδ̢ ̦δ̢͖ϳΦδ̦Ϯ
 ̟̓̋̅δ̰δ ̢̟̓Φδ̦̦ ̰̓ Ϧδ̰ ϳ̌ΰϳ͖ϳΰ͋Θ̅ ϳ̰̌̓
Iξ ̰ϰδ ϳ̌ΰϳ͖ϳΰ͋Θ̅̂ξΘ̋ϳ̅͝ ΰ̓δ̦ ̰̌̓ ̟Θ̵̢Φϳ̟Θ̰δ ̢̟̟̓δ̢ ̅δ͖δ̅ ̓ξ ΦΘ̢δ ̰̓ϰδ̢ ̰ϰΘ̌ ̐EϴϮ
ϳ̌ ̦δ̢͖ϳΦδ̦ ξ̢̓ ϲ΂ ΰΘ̦͝ϫ LMH! ̋Θ͝ Φ̦̓̌ϳΰδ̢
̦δ̌ΰϳ̌Ϧ Letter of Withdrawalϫ ΘϢδ̢ Φ̓̋̈
̟̅δ̵̌Ϧ Θ̌ΰ ΰ̓Φ͋̋δ̵̌̌Ϧ Θ̅̅ ̢δ̡͋ϳ̢δΰ δ̌̈
ϦΘϦδ̋δ̰̌ δῤ̢̰̦Ϯ ̑ϯίί ̎̀̚ϮΡ͘ Ϯϭͽͽϩϭ̒

̊ϳ̰ϰϳ̌ τ͖δ Υ̦͋ϳ̌δ̦̦ ΰΘ̦͝ϭ

 ̓̌τ̢̋ MδΰϳΦΘ̅ E̅ϳϦϳΥϳ̅ϳ̰͝ ̉δ̢ϳτΦΘ̵̓̌ ̔MẺ̕ ϳ̌ MHϴϮ

 ϴ͋Υ̋ϳ̰ Ǐϳ̵Θ̅ ϴδ̢͖ϳΦδ !̰͋ϰ̢̓ϳ͢Θ̵̓̌ Rδ̡͋δ̦̰ ξ̢̓ ̐Eϴ ̊Θϳ͖δ̢

̦δ̢͖ϳΦδ̦Ϯ

̉δ̢ϳξ͝ ̢̟͖̓ϳΰδ̢ ΘΥϳ̅ϳ̰͝ ̰̓ ̦͋Υ̋ϳ̰ Φ̅Θϳ̦̋ Υ͝ ̓̌δ

̓ξ ̰ϰδ ξ̓̅̅̓͗ϳ̌Ϧϭ
ϴδ̢͖ϳΦδ !̰͋ϰ̢̓ϳ͢Θ̵̓̌ ̊Θϳ͖δ̢ ̦δ̢͖ϳΦδ̦ ΥδϦϳ̌Ϯ
Θ̰͋ϰ̢̓ϳ͢δΰ Υ͝ DϴHϴ  ϺMHP Θ̰͋ϰ̢̓ϳ͢Θ̵̓̌ ̌͋̋Υδ̢Ϭ ̢̓

 ϴDϴHϴ !̰͋ϰ̢̓ϳ͢δΰϮϵ
 ̰̐̓͋ϰ E̟̋̓͗δ̢̋δ̰̌ ϴδ̢͖ϳΦδ̦ ̔̐Eϴ̕ ̊Θϳ͖δ̢
Ě̢̓̅̅̋δ̰̌ P̢̓Φδ̦̦

Ě̢̓̅̅̋δ̰̌ P̢̓Φδ̦̦ ξ̢̓ Ǐΰϳ͖ϳΰ͋Θ̅

͗ϳ̰ϰ̰̓͋ MδΰϳΦΘϳΰ
̊ϳ̰ϰϳ̌ ̦δ͖δ̌ Υ̦͋ϳ̌δ̦̦ ΰΘ̦͝ ̓ξ Φ̅ϳ̌ϳΦΘ̅ δ̅ϳϦϳ̈
Υϳ̅ϳ̰͝ ΰδ̌ϳΘ̅ϭ

 ϴδ̌ΰ Denial of Eligibility ̅δ̿δ̢ Θ̌ΰ Fair

Hearing Request ξ̢̓̋Ϯ

 P̢͖̓ϳΰδ ̢δξδ̢̢Θ̦̅ ̰̓ ̰̓ϰδ̢ ̦δ̢͖ϳΦδ̦Ϯ

NO
̅ϳ̌ϳΦΘ̅ E̅ϳϦϳΥϳ̅ϳ̰͝  ̟̓̋̅δ̰δ ̢̟̓Φδ̦̦ ̰̓ Ϧδ̰ ϳ̌ΰϳ͖ϳΰ͋Θ̅ ϳ̰̌̓
Θ̰͋ϰ̢̓ϳ͢δΰ Υ͝ DϴHϴϣ ̢̟̟̓δ̢ ̅δ͖δ̅ ̓ξ ΦΘ̢δ ̰̓ϰδ̢ ̰ϰΘ̌ ̐EϴϮ
̐Eϴ

̢̊Θ̟Θ̢̓͋̌ΰ FΘΦϳ̅ϳ̰Θ̢̰̓ϭ ̊ϳ̰ϰϳ̌ ̦δ͖δ̌ Υ̦͋ϳ̌δ̦̦ ΰΘ̦͝ ̓ξ MδΰϳΦΘϳΰ

NO ΰδ̌ϳΘ̅ϭ
 !̦̦ϳ̦̰̦ ͗ϳ̰ϰ MδΰϳΦΘϳΰ Θ̟̟̅ϳΦΘ̵̓̌ ̢̟̓Φδ̦̦Ϯ ̑ϯίί ̎̀̚ϮΡ͘
MδΰϳΦΘϳΰ Θ̟̟̅ϳΦΘ̵̓̌
Ϯϭͽͽ̒  ϴδ̌ΰ Denial of Eligibility ̅δ̿δ̢ Θ̌ΰ Fair
Θ̢̟̟͖̓δΰ Υ͝ HHϴϣ
Hearing Request ξ̢̓̋Ϯ
 ̵̓̌̌͋δ̦ ̢̊Θ̟Θ̢̓͋̌ΰ ̢̟̓Φδ̦̦ Υ͝ ΰδ͖δ̟̅̓ϳ̌Ϧ ̢ϳ̦ϳ̦
ϴΘξδ̰͝ P̅Θ̌Ϯ  P̢͖̓ϳΰδ ̢δξδ̢̢Θ̦̅ ̰̓ ̰̓ϰδ̢ ̦δ̢͖ϳΦδ̦Ϯ
̐Eϴ

Θ̌ Υϳ̅̅ ξ̢̓ P̢δ-δ̌ϦΘϦδ̋δ̰̌

̦δ̢͖ϳΦδ̦Ϯ ̑ϯίί ̎̀̚ϮΡ͘ Ϯ6ͽͽϩ9̒
ϴ͋Υ̋ϳ̰ Clinical Eligibility Determination Form
̰̓ DϴHϴϮ

P̢̓Φδδΰ ̰̓ Ě̢̓̅̅̋δ̰̌ P̢̓Φδ̦̦

ξ̢̓ Ǐΰϳ͖ϳΰ͋Θ̅ ͗ϳ̰ϰ MδΰϳΦΘϳΰ