FROM: PATRICK LUEBBERING, DIRECTOR
SUBJECT: INTRODUCTION OF THE REQUEST TO WITHDRAW OR CLOSE FORM
FORM REVISION #16
REQUEST TO WITHDRAW OR CLOSE
INSTRUCTIONS TO WITHDRAW OR CLOSE
This memorandum is to notify staff of the addition of the Request to Withdraw or Close Form and instructions to the IM Forms Manual. This form should be used in the event that a participant requests to withdraw his/her application or close a case. There are also fields to allow a participant to remove a person from an application or case.
Staff should review the form with the participant making the request and assist the participant in completing the form. Indicate any specific instructions from the participant in the space provided or attach additional sheets, if necessary.
EXAMPLE: Mrs. Jones would like to close her spend down coverage, but continue receiving SLMB.
Use this form for in-person contacts with participants only. Do not mail the form to a participant.
- Review this memorandum with appropriate staff.