Free 46015.FH8 - Indiana

NOTICE OF ACTION
Aged or Disabled
Name Address City, state, ZIP code

State Form 46015 (R5 / 7-01) / HCBS 0005

See the back of this form for important information about your responsibilities and appeal rights.
ICF / MR Medically Fragile Children
Medicaid number County Mailing date of notice (month, day, year)

NOTICE

Autism

TBI

AL

AFC

NEW APPLICATION

ANNUAL REDETERMINATION

CHANGE / UPDATE

The Indiana Family and Social Services Administration has taken the action indicated below in regard to your application for, or change of, services under the Home and Community-Based Services (HCBS) Waiver Program.
FOR APPLICATION ONLY

Effective ______________________________________, your application for services is:
Level of Care

Approved NF/TBI

Denied NF/AL NF/AFC

NF / Intermediate
Reason

NF / Skilled

ICF / MR

Hospital

Please check who approved Level of Care:

State

AAA Increased Decreased Continued at same amount Discontinued

FOR ANNUAL REDETERMINATION, CHANGE / UPDATE, AND DISCONTINUANCE ONLY

Effective ______________________________________, your waiver for services are:

Reason

Description of change

Redetermination of Level of Care completed?

By:

Yes

No

State
SERVICE

AAA
START DATE

Indep. C.M.
STOP DATE TOTAL HOURS AVE. HRS / MO.

SERVICES APPROVED PROVIDER - SPECIFY NAME AND ADDRESS

Case Management

Signature of case manager Address

Case manager's 9 digit authorization number Date (month, day, year) Case Mgr's 4 digit I.D. number Telephone number

(
I wish to appeal the above decision.
Reason:

)

IF YOU WISH TO APPEAL, PLEASE READ THE INFORMATION ON PAGE 2 AND THEN SIGN AND DATE BELOW.

Signature of applicant / recipient / guardian

Date (month, day, year)

YOUR APPEAL RIGHTS AS AN HCBS WAIVER SERVICES RECIPIENT

1. If you question the above action, you should discuss this matter with your waiver services case manager. 2. Your Right to Appeal and Have a Fair Hearing: If your application is denied, you may file an appeal within 30 days of the date the notice is mailed to you. As an HCBS waiver recipient, if you disagree with any action taken on your HCBS waiver case, you may appeal within 30 days of the effective date of the action. However, your HCBS waiver benefits will not continue unless you appeal prior to the effective date of action. If you appeal and your waiver benefits are continued and you lose the appeal, you may be required to repay assistance paid in your behalf pending the release of the hearing decision. 3. How to Request an Appeal: If you wish to appeal this decision, you may request an appeal within 30 days of the date of receipt of this decision. Sign and return this form or send a letter with your signature to: MS04, Indiana Family and Social Services Administration, Hearings and Appeals, 402 W. Washington St., Room W392, Indianapolis, IN 46204 If you send a letter rather than this Notice of Action, be sure that the letter contains your full name, address, and telephone number where you can be reached. Please attach a copy of this decision and state the name of the action you are appealing. If you are unable to write this letter, you may have someone assist you in requesting this appeal. A telephone request for an appeal cannot be accepted. You will be notified in writing by the Family and Social Services Administration, Hearings and Appeals of the date, time, and place for the hearing. Prior to, or at the hearing, you have the right to examine the entire contents of your case record maintained by the waiver case manager. You may represent yourself at the hearing or you may authorize a person to represent you, such as an attorney, relative, or other spokesperson. At the hearing you will have full opportunity to bring witnessses, establish all pertinent facts and circumstances, advance any arguments without interference and question, or refute any testimony or evidence presented.

Distribution of Notice of Action: Recipient BDDS Case File County DFC AAA Case File Assessment Agency Provider(s) Waiver Case File Other _____________________________________________