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Case Management Forms

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Comprehensive and Supports Waiver Forms 



Case Management Plan, Monitoring, and Billing Forms


·   NEW Home Visit and Service Observation Signature Form Posted 1-05-2015 in Word - PDF Version

·   Revised Case Management Guidance for Billing and Documentation Posted 12-09-2014

·   Community Integration Schedule Form Posted 10-27-2014

·   Case Management 15 Minute Unit Tracking Form Posted 10-21-2014

·   Case Management 15 Minute Unit Tracking Form Sample Posted 10-21-2014

·   Third Party Liability Form Docx Posted 5-1-2014

·   Third Party Liability Form PDF Posted 5-1-2014

·   Behavioral Support Service Sample Form Posted 4-2-2014

·   Behavioral Support Service Fillable Form Posted 4-2-2014

·   Crisis Intervention Service Request Form Posted 4-2-2014

·   Transportation Mileage Log Posted 4-2-2014

·   Case Management Monthly Review Form (effective 7-1-2012)
Case Management Quarterly - Effective September 2012, this form submitted electronically in Electronic Medicaid Waiver System (EMWS)


ECC and IBA Adjustment Forms


Employment Planning


Clinical Review Team Materials


For Level of Service Need Scoring Rubric, please reference the last page of the

Supports and Comprehensive Waiver Services Index Posted 4-24-2014

(Note SEFA Modifier change from UB to U8 and Companion Code correction)

Service Rate Fee Schedule (for Supports and Comprehensive Waivers) posted 4-23-14




IPC Documents and Related Materials

Note on opt out form:
Participant may request to opt out of receiving Support Brokerage services after the first year of self-directing at least one direct care service based on demonstrated competency in hiring, firing, training, supervising, scheduling workers, and reviewing timesheets in a timely manner.

The request to opt out shall be reviewed by the Participant’s Case Manager, who shall make an assessment of the Participant’s competency to self-direct successfully without a support broker.

The request and assessment shall be submitted to the Developmental Disabilities Section for approval. Instructions are on the form.


 ABI Waiver

         ·   ABI Waiver Neurological Requirements


 Supervision Flexibility Form

         ·   Supervision Flexibility Form Posted 2-27-14

Note: Providers who are implementing staffing flexibility must discuss the changes in staffing with the participant or guardian and case manager. This form must be signed by all parties and uploaded to EMWS in the person's document library by June 1, 2014.


 Targeted Case Management

  • Targeted Case Management Forms


 Team Meetings