(Revised 02/01/2017 ML #3489)
Purpose: To notify Aging Services/HCBS an MSP-Personal Care case was transferred to another county.
When prepared:
This form is to be completed for transfers related to MSP-Personal Cares. Do not submit to close a MSP-Personal Case.
Steps of Completion:
In the first section, always complete the County name and Case Manager Section. Also complete the Client Name: Record the first and last name
ID Number: Record the Medicaid recipient identification number.
Indicate on the form that this is a MSP-Personal Care case.
Transfer Case to Another County Section: Print the client’s last, first, and middle (initial) name; record the applicable ND identification number, the receiving county name, and the client’s new address (if known).Enter the date client is leaving current county and date client is entering new county.
The new HCBS Case Closure/Transfer Notice is due to Aging Services/HCBS within 3 working days from the date the County is made aware that the case is transferring to another County.
This form is not available from the state office. It is electronically available through the state’s e-forms.