DISCONTINUE CAP/C PARTICIPATION NOTICE Date TO: Provider Agency Provider Agency Address FM: Case Manager Case Management Agency Case Management Agency Address Case Management Agency Phone CLIENT'S NAME: ADDRESS: DOB: MID: DIAGNOSES: PARENTS/RESP. PARTY: ADDRESS: / Same as client’s PHONE: SEX: INSURANCE: PHONE: /Same as client’s The client’s authorization for CAP/C participation is: effective DISCONTINUED . SUSPENDED PAYER The following supplies from your agency are included in the CAP/C Plan of Care: CODE SUPPLY AMOUNT & FREQUENCY COST (If applicable) See attached listing of medical equipment and supplies. These supplies should NOT be provided after the effective date above. CAP/C Participation will not resume. CAP/C Participation will resume on authorization, on or after this date. , and supplies may be provided, as per the previous Thank you for helping coordinate care for this client. __________________________________________ Case Manager Name, CAP/C Case Manager 2/06
"DISCONTINUE CAPC PARTICIPATION NOTICE"