Free None - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Long Term Care F-21063 (08/2008)

STATE OF WISCONSIN

EXCEPTION TO CARE MANAGEMENT / SUPPORT AND SERVICE COORDINATION CONTACT REQUIREMENTS
All sections must be filled out completely and the form must be signed and dated by the participant (or guardian), care manager/support and service coordinator and supervisor to meet exception to contact requirements. Use of this form is optional. Name of Participant (Last, First, MI) Date of Request

Please answer the following questions. If the answer is "Yes," continue. If you answer "No" to any of the questions, STOP. An exception to care management/support and service coordinator contacts cannot be granted. Did the participant/guardian request this exception? Has at last six months passed since the participant's initial plan approval? Does the participant reside in his/her own home or apartment? 1. Yes Yes Yes No No No

Describe change in face-to-face care management/support and service coordination contacts requested by participant and the reasons the participant gave for making the request. (As a reminder, the six-month review of the service plan must occur during a face-to-face visit--there are no exceptions to this requirement.)

2.

Describe how the variables listed below would affect the frequency of care management/support and service coordination contact needed by the participant. a. Stability or frailty of the participant's health:

b.

Ability of the participant to direct his or her own care:

c.

Strength of in-home supports and the participant's informal support network:

F-21063, Exception to Care Management/Support and Service Coordination Contact Requirements

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d.

Stability of in-home care staff (e.g., historical frequency of turnover, availability of emergency back-up):

e.

Stability of the participant's care plan (e.g., historical and/or anticipated frequency of changes or adjustments to the plan):

f.

If applicable, the participant has lived in the community without EA/APS or critical incident for three years.

g.

If applicable, the participant has an active and interested guardian who is not a waiver service provider.

3.

Based on information in numbers 1 and 2 above, it is determined that care management contacts can be less than required by the waiver program. Care management/support and service coordination will be provided in the following way (describe who will provide services and frequency of contact):

SIGNATURE ­ Participant or Guardian SIGNATURE ­ Care Manager/Support and Service Coordinator SIGNATURE ­ Supervisor

Date Signed Date Signed Date Signed

The participant can reconsider the exemption from care management contacts at any time, but this request must be formally reviewed with the participant, care manager/support and service coordinator and supervisor, and a new form completed, every 12 months.