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EC

Ethan Cole

Rejected
IN-004116 · DOB 1983-04-26
Date Created
2026-04-09
Assigned Staff
Jordan Webb
ProviderOne ID
203118921WA
MedicAid Eligibility
Not Eligible
WLP Status
Disconnected
Service County
Not provided
Service City
Not provided
Disconnected Date
—

Program Health & Risk Information

Housing

Diagnosis

Not recorded

Health Factors

Not recorded

Risk Factors

Not recorded

Recorded during intake from the client's initial assessment.

Treatment Status

Unknown / Not Reported

Unknown / Not Reported

Defaults to Not Assessed. High or Medium risk clients appear on the Dashboard High & Medium Risk Clients widget.

Current Situation Duration

—

—

—

—

Enter the number of days based on the client's current situation.

Client Information

First Name
Ethan
Last Name
Cole
Date of Birth
1983-04-26
Phone Number
(360) 555-0162
Email
Not provided
Center
California
Program
Housing

Staff Assignment

Assigned Staff
Jordan Webb
Date Assigned
2026-04-09

Intake Status History

1 transitions · most recent first
StatusChanged ByDate / Time
RejectedSystem2026-04-09 09:00

Authorization Upload

System-generated from ProviderOne batch imports
UploadedRead-only · updated automatically after each successful import
Authorization / Assessment ID
AUTH-004116
ProviderOne #
203118921WA
Auth Start Date
—
Auth End Date
—
Benefit Limitation
—
Imported File
ProviderOne Determination Batch.xlsx
Import Date / Time
2026-04-09
Matched Via
ProviderOne

Document Readiness

Required before moving from Draft to New
Authorization
Uploaded
Consent Form
Uploaded
Pre-Qualify Eligibility Questionnaire
Uploaded