Appendix X, CCSE Case Management Filing Guide


Retention tab
Form 3052, Practitioner's Statement of Medical Need
Form 3055, Physician's Orders (DAHS)
Form 3050, DAHS Health Assessment/Individual Service Plan
Form 1582, Consumer Directed Services Responsibilities
Form 1584, Consumer Participation Choice
Form 1575, Medicaid Estate Recovery Program Worksheet
Form 8001, Medicaid Estate Recovery Program Receipt Acknowledgement
Form 2061, Notification of Medicaid Estate Recovery Program Status
Form 2307, Rights and Responsibilities
Interdisciplinary Team (IDT) Letters
Guardianship Documents
Forms Checklist for Attendant Care Programs

2019 tab
All forms created or received during this calendar year that are not required to be filed under the retention tab.

Filing Notes:

The Community Care Services Eligibility (CCSE) Case Management Filing Guide is a suggested filing format to promote consistency in CCSE case records.

The objective will be to always have the forms and documents which need to be retained on the top left side under Retention tab. All other forms and documents should be filed under yearly tabs beginning with 2019, 2020 and so on, with the current calendar year on the top right side. The intent of the yearly tabs is to file forms as they are created or received.