Appendix X, CCSE Case Management Filing Guide


Left Side

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

Right Side

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.