Free Children's Long-Term Support Waivers, HSRS Slot Change Request - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Long Term Care F-00102 (07/2009)

STATE OF WISCONSIN Bureau Of Long Term Support Children's Services Section

CHILDREN'S LONG-TERM SUPPORT WAIVERS HSRS SLOT CHANGE REQUEST
Completion of this form is voluntary. In lieu of this form, agencies may use locally designed forms with prior approval from the Children's Services Section. This form, or an approved substitute, is required for requesting the slot changes described below. Personally identifiable information on this form is collected to verify that the requested slot change is allowable, and will be used only for this purpose. Instructions: Choose the type of change being requested and complete all fields in that section. All supporting materials identified below as being included with this form must be included with this form. Forms that are missing required information will not be processed.

SWITCH PARTICIPANT'S MATCH SOURCE (Local-Match to State-Match, or vice versa)
Description: Participant continues to be eligible for waiver services, but county requests to switch the match source (e.g., localmatched to state-matched). Children's Services Section (CSS) approval is required ­ include a copy of the email or letter of approval from your CSS for this switch. Child must have a current disability determination for eligibility for a state-funded slot. County must close former slot in HSRS before submitting this form. Name ­ Participant (Last, First, MI) Effective Date of Change
(date county closed former HSRS slot)

Former Slot Number New Match Source Local Match State Match

Former LTS Code H I

J

K

L

M

Former Match Source Local Match State Match

New Slot Number requested
(leave blank if a new slot number needs to be created)

County has closed former HSRS slot effective date shown above (if not closed when form is submitted, change will not be processed). CSS has approved this change. Copy of CSS approval is included with this form.

SWITCH PARTICIPANT'S TARGET GROUP AT COUNTY OPTION (Child remains eligible for original Target Group)
Description: Waiver participant continues to qualify for original Level of Care and original match source, but also meets a different Level of Care per Children's Long Term Support (CLTS) Functional Screen in addition to the original Level of Care. County requests to switch child from one target group (waiver type) to the other for funding/contracting purposes. Requires prior approval by your CSS. County must close former slot in HSRS before submitting this form. Name ­ Participant (Last, First, MI) Effective Date of Change
(date county closed former HSRS slot)

Former Slot Number

Former Target Group DD PD SED

New Slot Number requested
(leave blank if number needs to be created)

New Target Group DD PD SED

County has closed former HSRS slot effective date shown above (if not closed when form is submitted, change will not be processed). CSS has approved this change. Copy of CSS approval is included with this form.

SUPPORT AND SERVICE COORDINATOR COMPLETING THIS FORM
Name (Type or Print) Email Address (Type or Print) (Confirmation will be sent to this email address) Telephone Number

Submit this form and all required documentation to:

Children's Waivers Unit DHS/DLTC/Children's Services Section PO Box 7851, Madison WI 57307-7851 E-Mail: [email protected]

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