Back to Intake Queue
CR

Carlos Rivera

Rejected
IN-004120 · DOB 1980-02-14
Date Created
2026-04-11
Assigned Staff
Marcus Hill
ProviderOne ID
203118874WA
MedicAid Eligibility
Not Eligible
WLP Status
Disconnected
Service County
Not provided
Service City
Not provided
Disconnected Date
—

Program Health & Risk Information

Employment

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
Carlos
Last Name
Rivera
Date of Birth
1980-02-14
Phone Number
(253) 555-0140
Email
Not provided
Center
California
Program
Employment

Staff Assignment

Assigned Staff
Marcus Hill
Date Assigned
2026-04-11

Intake Status History

1 transitions · most recent first
StatusChanged ByDate / Time
RejectedSystem2026-04-11 09:00

Authorization Upload

System-generated from ProviderOne batch imports
UploadedRead-only · updated automatically after each successful import
Authorization / Assessment ID
AUTH-004120
ProviderOne #
203118874WA
Auth Start Date
—
Auth End Date
—
Benefit Limitation
—
Imported File
ProviderOne Determination Batch.xlsx
Import Date / Time
2026-04-11
Matched Via
ProviderOne

Document Readiness

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