Draft NHTD Medicaid Waiver Program Manual 2021

Section XIV - All Documents

• Team Meeting 6-Month Timeline (PDF)
• DOH-5751 Moving Assistance Description and Initial Cost Projection (PDF)
• DOH-5752 Assistive Technology (AT) Description and Initial Cost Projection (PDF)
• DOH-5753 Environmental Modification (E-Mod) Description and Initial Cost Projection (PDF)
• DOH-5754 Regional Resource Development Specialist (RRDS) Final Cost for Environmental Modifications/vehicle Modifications (PDF)
• DOH-5755 Waiver Services Final Cost and Regional Resource Development Specialist (RRDS) Approval Of Final Cost(PDF)
• Agreement of Final Determination (PDF)
• Agreement of Understanding (PDF)
• Community Transitional Services (CTS) Description and Cost Projection HCBS Medicaid Waiver TBI and NHTD (PDF)
• DOH-5726 Initial Service Plan (PDF)
• DOH-5727 Service Coordination Agency Selection (PDF)
• DOH-5728 Freedom of Choice (PDF)
• DOH-5729 Application for Participation (PDF)
• DOH-5730 Provider Selection (PDF)
• DOH-5731 Change of Service Coordination Agency Request (PDF)
• DOH-5732 Waiver Participant Rights and Responsibilities(PDF)
• DOH-5734 Notice of Decision - Denial of a Waiver Service (PDF)
• DOH-5735 Notice of Decision - Increase or Addition (PDF)
• DOH-5737 Notice of Decision - Denial of Program (PDF)
• DOH-5738 Notice of Decision - Discontinuance (PDF)
• DOH-5739 Notice of Decision - Reduction and/or Discontinuation of Waiver Service(s) (PDF)
• DOH-5740 Notice of Decision - Authorization (PDF)
• DOH-5744 Notice of Decision - Death (PDF)
• DOH-5750 Change of Provider Request(PDF)
• DRAFT Addendum to Servicec Plan (PDF)
• DRAFT Plan for Protective Oversight (PDF)
• DRAFT Revised Service Plan (PDF)
• DOH-5747 Referral Form (PDF)
• LDSS-3139 Home Assessment Abstract (PDF)
• Individual Service Report (ISR) (PDF)
• ISP Review Form (PDF)
• NHTD Provider Address Grid (PDF)
• NHTD Sample Bid Submission Form for E MODS (PDF)
• NHTD TBI Provider Agreement (PDF)
• NHTD TBI RRDC Waiver Services Provider Interview (PDF)
• NHTD Waiver Initiative May 2021 (PDF)
• Serious Reportable Incident 24-Hour Provider Report (PDF)
• Serious Reportable Incident Provider Follow-up Report (PDF)
• Serious Reportable Incident Service Coordination 24-Hour Notification Report (PDF)
• RRDC Training Curriculum Checklist (PDF)
• RRDS Addendum Review Form (PDF)
• RRDS Revised Service Plan (RSP) Review Form (PDF)
• SAMPLE RRDC Status Report (PDF)
• SAMPLE RRDC Initial Response Report (PDF)
• Team Meeting Summary Form 2-15-2018 (PDF)
• Transportation Service Request Grid - Document Under Revision (PDF)
• Waiver Contact List Form (PDF)