Chapter 4. Home and Community Based Assessment, Care Planning and Authorization Process

Policy Number

Policy

4.00 Appendix 2a

Participant Choice Statement Form and Instructions (Agency, CDS, and ADC)
Form / Instructions

4.00 Appendix 2b

Participant Choice Statement Form and Instructions (RCF/ALF)
Form / Instructions

4.00 Appendix 3

In-Home Services Worksheet
Form / Instructions

4.00 Appendix 4

Consumer-Directed Services Worksheet
Form / Instructions

4.00 Appendix 5

Physician Notification
Form / Instructions

4.00 Appendix 8

SLUMS
Form / Instructions

4.00 Appendix 10

Self Direction Assessment Questions
Form / Instructions

4.00 Appendix 11

Participant Contact Letter
Form / Instructions

4.00 Appendix 13

Healthcare Professional Inquiry
Form / Instructions

4.00 Appendix 14

HCBS Assessment Attestation
Form / Instructions

4.00 Appendix 15

Healthcare Information Request
Form / Instructions

4.00 Appendix 16

Structured Family Caregiving Waiver Diagnosis Verification
Form / Instructions

Chapter 5. Adverse Action

Policy Number

Policy

5.00 Appendix 3

Adverse Action
Form / Instructions

5.00 Appendix 4

Application for a State Hearing
Form / Instructions

5.00 Appendix 5

Reversal of Adverse Action
Form / Instructions

5.00 Appendix 6

Notice of Closure
Form / Instructions