HCBS Document Library

Participant Direction FMS Change Notification Form – Effective 10/2022

Participant Direction Employer Manual – Effective 2/2021

Participant Direction Employee File Checklist – Effective 8/2022
English Ι Español

Participant Direction EOR Designation and POA Form – Effective 11/2021

Participant Direction EOR Agreement Form – Effective 11/2021

Participant Direction Support Plan – Effective 2/2021
English Ι Español

Skilled Nursing PA Request Form – Updated 2/2022

Instructions for Skilled Nursing PA form – Updated 2/2022

Application for Waiver Services – You will be redirected. Application found under First Steps

Case Management Selection Form – You will be redirected. Form found under First Steps

Case Management Agency Case Manager Update Form – Updated 7/2022

ECC Checklist – Updated 5/24/2022

ECC Request – Updated 5/10/2021

ECC Team Consensus Form – Updated 5/24/2022
English Ι Español

Environmental Modification Request Worksheet – Updated 12/2022

Home Visit and Service Observation Signature Form – Updated 3/2022
English Ι Español

ICAP Authorization and Information – Updated 1/2022
English Ι Español

IPC Team Meeting Checklist – Updated 11/2022

Medication Consent Form – Updated 11/2022

Participant-Direction Referral Form – You will be redirected. Search for form using Wyoming Department of Health / WY Referral Form

Positive Behavior Support Plan – Updated 4/2022
English Ι Español

Provider Controlled Setting Certification Checklist – Updated 7/2022

Provider Documentation Non Compliance Form – Updated 2/2022

Remote Monitoring Risk Assessment – Updated 9/2022
English Ι Español

Request for Prior Authorization of Skilled Nursing Services – Instructions

Skilled Nursing Physician Order Form

Specialized Equipment Request Worksheet – Updated 11/2021

Targeted Case Management 15 Unit Tracking – Updated 2/2022

Targeted Case Management Plan of Care
English Ι Español

Third Party Liability Form – Updated 1/2022

Transition Checklist – Updated 12/2022

Initial Certification and Renewal Certification Required Forms

• Annual Self Inspection Requirements – Updated 11/2022
• Case Manager Demonstration of Understanding – Updated 9/2021
• Conflict Free Case Manager Confirmation – Updated 9/2022
• Continuing Education Tracking Record – Updated 9/2021
• Declination of Medication Assistance – Updated 9/2022
• Documentation Standards – Updated 9/2022
• Emergency Plan Review Form – Updated 9/2021
• No Services Provided in a Provider Operated Setting – Updated 9/2021
• Provider Staff File Checklist – Updated 9/2021
• Provider Statement of Confidentiality Form – Updated 9/2021
• Provider Demonstration of Understanding – Updated 9/2021
• Provider Vehicle Information Form – Updated 11/2022

Examples and Templates

• Policies and Procedures
  • Case Management Policies and Procedures – Updated 11/2022
  • Critical Incident Reporting Policy and Procedure – Updated 10/2022
  • General Policies and Procedures – Updated 10/2022
  • Internal Incident Reporting Policy and Procedure – Updated 10/2022
  • Medication Assistance Policy and Procedures – Updated 4/2020
• Emergency Plans
  • Community Based Services – Updated 11/2022
  • Home Based Services – Updated 11/2022

The examples and templates found here do not replace required documentation and are for illustration purposes only.

Code of Conduct Example – Updated 2/2022

Medical Assistance Record (MAR) – Updated 2/2022

Participant Specific Training – Updated 2/2022

Schedule – Habilitative Services – 1/2022

Schedule – Non-Habilitative Services – Updated 1/2022

Task Analysis – Updated 11/2022

Transportation Mileage Log – Updated 1/2022

Find tools, handbooks, and other useful information below.

Application for Waiver Services Guide – You will be redirected. Guide found under First Steps.

Certification Renewal Required Documents – Updated 7/2022

Commonly Used Acronyms – Updated 11/2022

Commonly Used Terms – Updated 11/2022

Conflict Free Case Management Information – You will be redirected.  Criteria found under Reference Materials toggle.

Criteria for DD Psychological Evaluations – You will be redirected.  Criteria found under Reference Materials toggle.

Criteria for Neuropsychological Evaluations – You will be redirected.  Criteria found under Reference Materials toggle

DD Rate Increase & Attestation Presentation • DD Rate Increase Calculation Tool

EMWS File Naming Convention Guidelines – Updated 11/2022

IPC Guide – You will be redirected.  Guide found under Reference Materials toggle.

IPC Planning Workbook – You will be redirected. Planning Workbook located under “First Steps”

Partnership Access Line (PAL) Consultation Process – Updated 1/2022
English Ι Español

Positive Behavior Support Plan Manual – Updated 4/2021
English Ι Español

Provider On-Site Safety Standards – Updated 9/21/2020
English Ι Español

Relative Provider Clarification Chart – Updated 2/16/2022
English Ι Español

Rights Restriction Review Tool – Updated 1/2022
English Ι Español

Wyoming Health Provider (WHP) Portal Guidance Documents

DD Waiver Provider Application Guidance Manual

Electronic Corrective Action Plan (CAP) Guidance Manual Ι CAP Demo video 21:21

Provider Change Guidance Manual

Provider Portal Administration Guidance Manual

Provider Complaint Process Manual Ι Complaint Submission Demo Video/9:50

Tips, Best Practices and FAQs

Electronic Medicaid Waiver System (EMWS) Guidance Documents

CCW Leave of Absence Back Up Case Manager Assignments – Updated 4/26/2022

CCW Participant-Direction Budget Worksheet – Updated 5/2022

On-Hold & Closure Process Guidance Document – Updated 4/19/2022