Form 3623, Approval of Application for CLASS

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Effective Date: 8/2011


Updated: 8/2011


To notify an applicant of eligibility for the Community Living Assistance and Support Services (CLASS) program.


When to Prepare

The case manager completes Form 3623 when the applicant is determined eligible for enrollment into the CLASS program. This form is completed when all eligibility requirements have been met and an effective date on which the individual is eligible to begin receiving CLASS services has been determined.


The case manager retains the completed form and provides a copy to the individual/legally authorized representative (LAR) and the direct service agency (DSA).

Form Retention

Keep this form according to record retention requirements documented in the CLASS Provider Manual.

Detailed Instructions

Applicant's Name and Address — Enter the applicant's name and mailing address in the space provided.

Date — Enter the date Form 3623 is completed.

Office Address and Telephone No. — Enter the name, address and telephone number of the case management agency.

Applicant's Medicaid No. — Enter the applicant's Medicaid number.

Approval of Application for CLASS — Enter the effective date the applicant is determined eligible to begin receiving services. This date is the date entered on Item 11, Effective Date, Form 3621, CLASS Individual Plan of Care.

Name of DSA — Enter the name of the DSA of record.

Name of CMA — Enter the name of the CMA of record.

Name of CDSA — Enter the name of the CDSA of record.

Signature – Case Manager — The case manager signs the form.