Form 2068, Application/Redetermination or Monitoring for Community Care Services

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Effective Date: 9/2017


Updated: 2/2009


  • To serve as a cover letter for applications/redeterminations and monitoring contacts.
  • To notify individuals of an appointment to determine/redetermine eligibility for services.


When to Prepare

Send Form 2068 with each application/redetermination form. When needed, also send Form 2068 to inform an applicant or individual of a scheduled appointment.

Number of Copies

Complete an original and one copy.


Send the original to the applicant/individual and retain the copy in the case record.

Form Retention

Retain the case record copy for three years.

Detailed Instructions