Free Individual Service Plan - Medicaid Waivers - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Long Term Care F-20445 (08/2008)

STATE OF WISCONSIN

INDIVIDUAL SERVICE PLAN ­ MEDICAID WAIVERS
1 Waiver Program CIP II COR 3 Individual's Name 5 Mailing Address (If Different) COP-W CLTS DD CIP 1A CLTS MH CIP 1B CLTS PD BIW 1a Plan Type (Check ALL That Apply) New Six Month Review Annual Recertification CLTS Crisis Update CLTS Pilot 4a City, State 7 E-Mail 8 Service Plan Development Date 2 Medicaid ID Number

4 Address (street) 6 Telephone

4b Zip Code 9 Functional Screen Date

10 Cost Share Amount

11 Level of Care

12 Parental Fee (If Applicable)

13 Personal Discretionary Funds Available

14 [Reserved]

15 Start Up/OneTime Cost -Total

16 Waiver Cost/Day Total

17 Prior Living ArrangementHSRS Code 21 Waiver Agency

18 Prior Living Arrangement-Name/Type

19 Current Living ArrangementHSRS Code

20 Current Living Arrangement-Name/Type

22 Agency Telephone No.

23 Support & Service Coordinator/Care Manager (SSC/CM) 26 Mailing Address (SSC/CM) 28 E-mail Address (SSC/CM) 30 Telephone No. (Home) 33 City 37 Telephone No. (Cell)

24 SSC/CM Telephone No./Ext.

25 Mailing Address (Agency) 27 E-mail Address (Agency) 29 Name ­ Parent(s) or Guardian 32 Mailing Address (Street/PO Box) 36 E-mail Address IN CASE OF EMERGENCY, NOTIFY: 38 Name 41 Address

City

State

Zip

31 Telephone No. (Work) 34 State 35 Zip

39 Telephone No. (Home) 42 City

40 Telephone No. (Work) 43 State 44 Zip 45 Relationship

F-20445 Page 2
62 Service Code # 64 Outcome 65 Service Provider Name Address and Telephone No. (E-mail, cell phone No. (Fno., if known) 20445a #5) 67 Authorized Units of Service and Frequency (#/day or week or month) 68 Daily Cost (total yearly ÷ 365 days)

63 Service Name

65a Start Date

65b End Date

66 Unit Cost ($/hr; day)

69 Funding Source

F-20445 Page 3 70 I have been informed that I have a choice between an ICF-MR or nursing home (dependent on waiver type) and community services through a Medicaid Home and Community Waiver Program. I have been informed of and understand my choices in the waiver programs, including approval or rejection of the services and providers listed on this service plan. I have been informed of and understand my rights and responsibilities in the Medicaid Home and Community Waiver Programs. I was informed verbally and in writing of my rights and responsibilities. By my signature below I indicate I have chosen to accept community services through a Medicaid Home and Community Waiver Program. SIGNATURE - Participant SIGNATURE ­ Guardian/Authorized Representative/Parent SIGNATURE - Witness Date Signed Date Signed Date Signed SIGNATURE ­ Support and Service Coordinator/Care Manager SIGNATURE - Guardian/Authorized Representative/Parent SIGNATURE ­ Witness Date Signed Date Signed Date Signed

Distribution: DHS, County Care Manager/Support and Service Coordinator, Individual, Authorized Representative

F-20445 Page 3B CIP II/COP-W CBRF Variance Request [Check () the type of variance requested) A variance to the 20-bed CBRF size limitation for an individual that is elderly A variance to allow waiver funding for an individual that is elderly to reside in a CBRF connected to a nursing home By signing below, the Support and Service Coordinator / Care Manager attests to the following: 1. The environment is non-institutional and the facility operates in a manner than enhances resident dignity and independence, and 2. The facility is the preferred residence of the applicant/participant or his/her legal representative. 70 I have been informed that I have a choice between an ICF-MR or nursing home (dependent on waiver type) and community services through a Medicaid Home and Community Waiver Program. I have been informed of and understand my choices in the waiver programs, including approval or rejection of the services and providers listed on this service plan. I have been informed of and understand my rights and responsibilities in the Medicaid Home and Community Waiver Programs. I was informed verbally and in writing of my rights and responsibilities. By my signature below I indicate I have chosen to accept community services through a Medicaid Home and Community Waiver Program. SIGNATURE - Participant SIGNATURE ­ Guardian/Authorized Representative/Parent SIGNATURE - Witness Date Signed Date Signed Date Signed SIGNATURE ­ Support and Service Coordinator/Care Manager SIGNATURE - Guardian/Authorized Representative/Parent SIGNATURE ­ Witness Date Signed Date Signed Date Signed

Distribution: DHS, County Care Manager/Support and Service Coordinator, Individual, Authorized Representative