Self-declaration Effective Date 620-01-30-05

(Revised 1/1/14 ML #3393)

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PI 22-03

 

 

The earliest effective date for a new self-declaration will be the date that both the fingerprint background check memo and the authorized agent signature have been received. All required materials must be received by the authorized agent by this date.

 

The date the regional office signs the self-declaration document may then be different than the effective date of the self-declaration.

 

Example:

 

	Provider signs/notarization	June 2nd
	Stamped in at the county	June 3rd
	Authorized agent signs	June 8th
	Pre-approval visit	June 8th
	Fingerprint memorandum dated	July 1st
	Regional office signs	July 7th
	Effective date	July 1st

 

The regional office should contact the central office if there appears to be a problem with timely issuance of SFN 865.

 

The regional office should contact the central office if special circumstances apply that would require a different effective date.