Free Home Modification Request for a Ramp - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Long Term Care F-21055 (08/2008)

STATE OF WISCONSIN

HOME MODIFICATION REQUEST FOR A RAMP
A modification request is required under the Human Service Reporting System SPC 112.56. Use of this form is optional. Name ­ CM/SSC or Social Worker Email Address Name ­ COP-W / CIP II / CIP Participant County/Agency Date of Request Telephone No.

Does participant reside in a substitute care facility (AFH, CBRF, RCAC)? Yes No · If Yes, STOP. As per the Medicaid Waiver Manual, "Excludes payments for modifications to a licensed or certified substitute care facility. In these facilities, repairs and/or modifications are a cost of facility operation." As a result, this home modification request cannot be approved. · If No, continue. Does the participant live in a home owned by another person or in an apartment? · If yes, has the dwelling owner approved of this construction? Explain how the proposed ramp will meet the participant's assessed need or desired outcome. Yes Yes No No N/A

NOTE: With this request, please send (fax or mail) a diagram of the proposed ramp to TMG or CIS, with a copy of an updated ISP (signed and dated by the participant) with this home modification added.

Specifics of Ramp and Landing (To be completing by contractor or CM/SSC or social worker)
1. 2. 3. 4. 5. What is the measurement of the distance from the door threshold down to the ground? What is the measurement of the distance between the door threshold and top landing? What are the dimensions of the top landing? (should not be less than 5' x 5' or greater than 8' x 8') What is the length of the ramp? Are there resting/turning areas in the ramp? If yes, what are the dimensions of those resting/turning areas? 6. What is the pitch of the ramp? (should not be steeper than 1:12" pitch) If the pitch is steeper than 1:12", please provide information as to how the participant will be able to manage the proposed steepness of the ramp. NOTE: Ramps steeper than 1:8" will not be approved. Are there railings on both the landing and ramp? Does the ramp have a raised edge? (NOTE: These are not needed if there are railings) Is there a need to have a solid surface landing at the end of the ramp for easy transferring/transitioning? If Yes, What is the material of the landing? (cement, wood, other) 10. What are the dimensions of the landing at the end of the ramp? Breakdown of Costs Material: Labor: Date Approved/Denied Yes Yes Yes No No No N/A Yes No

7. 8. 9.

SIGNATURE ­ QAC or CIS Approved Denied Reason for denial (if applicable)

F-21055 (08/2008)

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DOCUMENTATION OF RAMP CONSTRUCTION
The following is a means to document that the ramp was constructed according to local or state codes and regulations. It is not mandatory that this specific page be utilized; however, it is important that the information listed is documented within the file in some manner. The Medicaid Waiver standards require that the ramp be built to all applicable local and state housing or building codes. The following statement may be used to meet this standard.

My signature attests that the wheelchair ramp and landing has been built in accordance with all applicable local and state housing or building codes and are subject to any inspection required by the municipality responsible for administration of the codes.
SIGNATURE ­ Builder/Contractor Date Signed

Building Permit required? Building Permit obtained? (if required) Builder Insured? (if applicable)

Yes Yes Yes

No No No

N/A N/A

SIGNATURE ­ CM/Social Worker

Date Signed