3.55 Appendix 2 Waiting List Notice for ILW Services Instructions
Home and Community Based Services Manual
3.55 Appendix 2 Waiting List Notice for ILW Services Instructions
Revised - March 2025
Participants who meet all required eligibility criteria to participate in the Independent Living Waiver (ILW) are placed on the ILW Waiting List when no slots are available for enrollment. The Waiting List Notice for Independent Living Waiver Services (HCBS-12w) provides the participant and/or their authorized representative (e.g. guardian, or someone with a signed Authorization for Disclosure of Consumer Medical/Health Information that is in effect) with written notification of the participant’s number on the ILW Waiting List, along with appeal rights related to their number.
INSTRUCTIONS
Enter the date the letter is completed.
Enter the participant’s name and address.
- For participants that have a guardian, enter the guardian’s contact information.
Enter the participant’s number on the ILW Waiting List.
Enter the date of the participant’s most recent assessment in the two locations indicated.
Enter the name and signature of DSDS staff completing the form, along with the office address and telephone number.
DISTRIBUTION
The original HCBS-12w shall be mailed to the participant and/or their authorized representative. A copy shall be uploaded to the participant’s electronic case record.
A copy shall also be included in the exhibit packet sent to the Department of Social Services (DSS), Division of Legal Services (DLS) when a hearing is requested.