WAG 20-05-01: Notice of Restriction

PM 20-05-01.

  1. (RRP Unit) Sends the caretaker relative or payee the following forms and a pre-addressed stamped envelope:
    • HFS 3051, Notice of Restriction to: Primary Care Physician (Doctor) Only/Primary Care Pharmacy Only/Both Primary Care Physician (Doctor)/Pharmacy, and
    • HFS 3052, Choice of: Primary Care Physician (Doctor) Only/Primary Care Pharmacy Only/ Both PC Physician (Doctor)/Pharmacy.

      NOTE: The notices provide a toll-free number, 1-800-325-8823, for clients to call if they have any questions. 

  2. (Client) Completes HFS 3052, if they want a different provider than HFS assigns.
  3. (RRP Unit) Contacts provider the client chooses to verify their willingness to be the primary care provider.
  4. (RRP Unit) Sends HFS 3053, Confirmation of Primary Care Provider, to client, if provider agrees to be the primary care physician or pharmacy.

    NOTE: For AFDC clients, if the client chooses an HMO the entire unit will be enrolled. 

    1. Sends:
      • HFS 3056A, Confirmation of Primary Care Physician; or
      • HFS 3056B, Confirmation of Primary Care Pharmacy;

        as appropriate.