Takeback Request Form CS - Takeback Request Form "*" indicates required fields Client Name* First Last Date of Birth* Month Day Year PMI*Case Manager Name* First Last Case Manager Phone*Case Manager Email* County of Financial Responsibility*Date of Service* Month Day Year End Date of ServiceIf multiple dates of service Month Day Year Reason for Takeback Request* In facility Out of community Transitional Services Unused Funds Waiver reinstatement Other - Please describe below Procedure Code* S5120/S5121 S5165 T2003.UC T2038 T2038.U1 T2038.U2 Other If Transportation Bus Lyft Specialty/Taxi T2038 Total SpentT2038.U1 Total SpentT2038.U2 Total SpentOther Procedure CodeAdditional InformationCAPTCHA
