Individual Information (Complaint)
This screen allows users to enter information about an individual. The first time this screen loads, it will display the individual search screen. If a user searches for and selects an individual, their information will automatically be populated in read-only mode on this screen. Users may also choose to continue without selecting an individual. When this occurs, users will need to enter demographic information for the individual.
Note: Mandatory fields are marked with an asterisk. You must complete all the mandatory fields on a screen. In addition, some fields become mandatory as a result of your answer to previous fields.
Field Name |
Field Description |
MCI Number |
The Master Client Index (MCI) number is displayed in a read-only format. |
SSN |
The Social Security Number (SSN) is displayed in a read-only format. |
Waiver/ Program |
This field contains information about the Waiver/ Program in which an individual is enrolled. |
First Name |
Enter the first name of the individual. |
Last Name |
Enter the last name of the individual. |
Middle Initial |
Enter the middle initial of the individual. |
Suffix |
Enter the suffix of the individual's name, if applicable. |
Gender |
Select the gender of the individual from the drop-down list. |
Date of Birth |
Select the date of birth of the individual. |
Phone |
Enter the phone number of the individual. |
Enter the e-mail address of the individual. |
|
Address Line 1 |
Enter the street address of the individual. |
Address Line 2 |
Enter the second line of the individual's address. |
Address Line 3 |
Enter the third line of the individual's address, if applicable. |
City |
Enter the city corresponding to the above address. |
County |
Enter the county corresponding to the above address. |
State |
Enter the state corresponding to the above address. |
Zip Code |
Enter the zip code corresponding to the above address. |