Free Variance Request - Wait List - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Long Term Care F-00076 (06/2009)

STATE OF WISCONSIN

VARIANCE REQUEST ­ WAIT LIST
A variance request is required in order to receive an exception to the Medicaid Home and Community-Based Waiver wait list policy. Use of this form is optional.

Name ­ Applicant Potential Funding Source (Check one) COP ­ W CIP II BIW Name - Agency and Care Manager / Support and Service Coordinator Detail reason applicant should receive variance to statewide waitlist policy:

Date of Request

CIP IA CIP IB

CLTS DD CLTS PD CLTS SED

Submit variance request to: · COP-W / CIP II ­ Kimberly Schindler (BLTS) · CIP 1A / 1B ­ Community Integration Specialist (CIS) · CLTS ­ Children's Services Specialist (CSS) Approved Denied SIGNATURE ­ Authorized BLTS Representative Date Approved/Denied