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.