How to Complete the Medicaid Community Engagement Requirement Form

Follow this step-by-step guide to complete your information, report qualifying activities, submit verification requests, and receive your completed forms.

1

Enter Your Personal Information

When you open the form, you will first be asked to provide your basic personal information.

Email: Enter the email address where you want to receive your completed forms and updates.
First Name: Enter your first name.
Last Name: Enter your last name.
Date of Birth: Enter your date of birth.
State Issuing Medicaid: Select the state that issues your Medicaid benefits.
Medicaid Community Engagement Requirement Exemption: Select an exemption if one applies to you.
Important: The next step depends on whether you select an exemption.
2

If You Qualify for an Exemption

If you select an exemption from the Medicaid Community Engagement Requirement Exemption list, a button labeled Sign and Generate Form will appear.

Sign the Form

  1. Click Sign and Generate Form.
  2. A signature window will appear.
  3. Use the signature area to provide your signature.
  4. Submit your signature when you are finished.
  5. The system will generate your form.
  6. A download link for the completed form will be sent to the email address you provided.
No additional activity information is required when you are submitting an exemption.
3

If You Do Not Select an Exemption

If you do not select an exemption, click the Next button to continue to the second section of the form.

In this section, you will provide information about the activities you are reporting for the Medicaid Community Engagement Requirement.

You can add multiple activity records if you have participated in activities for different organizations or under different verification types.
4

Select a Verification Type

The first field in the activity section is Verification Type.

Select the option that best describes the activity you are reporting:

  • Work Verification
  • Caregiver Verification
  • Volunteer Verification
  • Student Verification

After selecting a verification type, the available organizations will be updated based on your selection.

5

Select the Organization and Contact

Organization Name

Use the Organization Name dropdown to select the organization where you performed the reported activity.

The organization list is filtered according to the Verification Type you selected.

Contact

After selecting an organization, use the Contact field to select the person who should verify your information.

The selected contact will receive a verification request and will be asked to review the information you submitted and confirm whether it is accurate.

Add a New Contact to an Existing Organization

If you selected an existing organization, but the person you want to use as the contact does not appear in the Contact list, you can add a new contact to that organization.

To do this, select the option Enter organization contact from the Contact field.

A window will appear where you can enter the information for the new contact.

Contact First Name: Enter the contact's first name.
Contact Last Name: Enter the contact's last name.
Role of the contact within the organization: Enter the position or role the contact holds within the organization.
Contact Email: Enter the contact's email address.
Contact Phone: Enter the contact's phone number.

After completing all the required information, click Add Contact.

The new contact will be added to the selected organization and will become available to select in the Contact field.
6

Add a New Organization

If the organization you need is not listed, select Enter new organization from the Organization Name dropdown.

A window will appear asking you to enter information about the organization and your immediate supervisor or appropriate contact.

Organization Name: Enter the organization's name.
Supervisor/Manager Name: Enter the name of your immediate supervisor or appropriate contact.
Role: Enter the supervisor's or contact person's role within the organization.
Email: Enter the contact person's email address.
Phone: Enter the contact person's phone number.

After entering the required information, click Add Organization.

The new organization and contact will be added to the system and automatically selected in the form.
7

Enter Your Activity Information

Once the organization and contact have been selected, complete the remaining information for the activity.

Role: Describe the position, role, or type of work you performed at the organization.
Hours: Enter the number of hours you completed for the reported activity.

Supporting Documents

You may also upload supporting documentation as evidence of your activity.

  • PDF documents
  • Image files

Upload any documentation that may help verify the activity you are reporting.

8

Add the Activity Record

After completing all the information for the activity, click Add Entry.

The activity will be added to a list of your entries.

You can repeat this process as many times as necessary to report additional activities.

  1. Select a different Verification Type, if applicable.
  2. Select the appropriate Organization Name.
  3. Select the appropriate Contact.
  4. Enter your role.
  5. Enter the number of hours.
  6. Upload supporting documentation, if applicable.
  7. Click Add Entry.
Continue adding entries until you have reported all the activities you want to submit for verification.
9

Review and Submit Your Entries

Before submitting your information, carefully review the list of entries you have added.

  • Make sure the verification type is correct.
  • Make sure the organization is correct.
  • Make sure the selected contact is the appropriate person.
  • Make sure your role is accurate.
  • Make sure the number of hours is correct.
  • Make sure your supporting documents are appropriate.

Once you have finished adding and reviewing your entries, click Save and Submit for Verification.

10

Submit Your Information for Verification

When you click Save and Submit for Verification, your information will be saved and a verification request will be sent for each activity entry.

Each organization contact will receive a request containing a link to review the information associated with their organization.

The Contact Can:

  1. Open the verification link.
  2. Review the activity information.
  3. Confirm that the information is accurate.
  4. Reject the request and provide a reason for the rejection.
Each contact will only review the activity record associated with their organization.
11

If Your Information Is Confirmed

When an organization contact confirms your activity information, you will receive a link at the email address you provided.

Use this link to download the form signed or verified by the organization contact.

If you submitted multiple activity entries, each verified entry may have its own completed verification form.
12

If Your Information Is Rejected

If an organization contact rejects a verification request, you will receive a link where you can view the rejection information.

The rejection page will explain the reason provided by the organization contact for rejecting the request.

Review the rejection reason carefully to determine whether you need to correct the information or take additional action.

Quick Overview

If you select an exemption:

Personal Information  →  Select Exemption  →  Sign and Generate Form  →  Sign  →  Form Generated  →  Download Link

If you do not select an exemption:

Personal Information  →  Next  →  Verification Type  →  Organization  →  Contact  →  Role & Hours  →  Evidence  →  Add Entry
Add More Entries  →  Save and Submit for Verification  →  Contact Reviews  →  Confirm or Reject  →  Completed Form or Rejection Information

Important Notes

  • Make sure the email address you enter is correct. Your completed forms, verification updates, and download links will be sent to this address.
  • Select the verification type that accurately describes the activity you are reporting.
  • Make sure you select the correct organization and the appropriate contact person.
  • Provide accurate information about your role and hours.
  • Upload supporting documentation when available and appropriate.
  • You can add multiple activity entries before submitting the form.
  • Each organization contact will receive a verification request for the activity associated with their organization.
  • Keep access to your email after submitting the form so you can receive download links and verification updates.