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Downloading a Form to Your Computer
Fillable forms cannot be viewed on mobile or tablet devices. Follow the steps below to download and view the form on a desktop PC or Mac.
Right Click for PC or
Ctrl + Click for Mac on the PDF link and click “
Save link as” from the menu.
Select the folder you want to save the file in and then click
Save.
Right Click for PC or
Ctrl + Click for Mac, then select
Note: Open the PDF file from your desktop or Adobe Acrobat Reader DC.
Do not click on the downloaded file at the bottom of the browser since it will not open the PDF in Adobe Acrobat Reader DC. It will try to open the file in the browser that results in the same browser error message.
Enter the legal name of the LIDDA completing the form.
2. LIDDA Component Code
3. LIDDA Mailing Address
80. Managed Care Organization (MCO) or Department of State Health Services (DSHS) Name
Enter the name of the MCO chosen by the individual for CFC services or name of DSHS.
81. MCO Component Code
Enter the component code associated with the MCO chosen by the individual for CFC services. If DSHS, leave this field blank.
82. Plan Code
4. Individual’s Name (Last/First/Middle)
Enter the individual s last name, first name and middle name or initial.
10. Individual’s Date of Birth
Enter the individual s date of birth in MM-DD-YYYY format.
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