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MT

Mia Thompson

Declined
IN-004123 · DOB 1989-06-17
Date Created
2026-04-12
Assigned Staff
Sofia Alvarez
ProviderOne ID
Not provided
MedicAid Eligibility
Pending
WLP Status
Pending
Service County
Not provided
Service City
Not provided

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

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Current Situation Duration

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

Client Information

First Name
Mia
Last Name
Thompson
Date of Birth
1989-06-17
Phone Number
(206) 555-0103
Center
Washington State
Program
Employment

Staff Assignment

Assigned Staff
Sofia Alvarez
Date Assigned
2026-04-12

Intake Status History

1 transitions · most recent first
StatusChanged ByDate / Time
DeclinedSystem2026-04-12 09:00

Authorization Upload

System-generated from ProviderOne batch imports
Not UploadedRead-only · updated automatically after each successful import
No matching authorization has been uploaded for this client.

Document Readiness

Required before moving from Draft to New
Authorization
Not Uploaded
Consent Form
Uploaded
Pre-Qualify Eligibility Questionnaire
Uploaded