"Medicaid Waiver, Provider, and Services Choice Statement Form" - Missouri

Medicaid Waiver, Provider, and Services Choice Statement Form is a legal document that was released by the Missouri Department of Mental Health - a government authority operating within Missouri.

Form Details:

  • Released on August 7, 2013;
  • The latest edition currently provided by the Missouri Department of Mental Health;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Missouri Department of Mental Health.

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Download "Medicaid Waiver, Provider, and Services Choice Statement Form" - Missouri

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STATE OF MISSOURI
DEPARTMENT OF MENTAL HEALTH
DIVISION OF DEVELOPMENTAL DISABILITIES
MEDICAID WAIVER, PROVIDER, AND SERVICES CHOICE STATEMENT
INDIVIDUAL NAME
DATE OF BIRTH
MEDICAID NUMBER
DMH ID NUMBER
Choice to Participate in a Division of Developmental Disabilities Waiver
As an alternative to placement in a long term care facility known as an Intermediate Care Facility for Mental Retardation (ICF/MR),
you have been recommended for participation in the following Division of Developmental Disabilities Medicaid Home and
Community-Based Waiver program:
[ ] Comprehensive Waiver [ ] Community Support Waiver [ ] Sara Jian Lopez Waiver [ ] Autism Waiver
[ ] Partnership for Hope Waiver
You may request services through this Medicaid Home and Community-Based Waiver, or you may request referral to an ICF/MR
facility. Please indicate your choice of the following services:
I wish to participate in the Medicaid Home and Community Based Waiver program specified above. I understand that
participation is conditional based on my eligibility for Medicaid and other criteria.
I wish to be referred to an ICF/MR facility.
I HAVE RECEIVED INFORMATION REGARDING THE OPTION TO SELF-DIRECT MY SERVICES’ AS WELL AS
INFORMATION FOR QUALIFIED AGENCY SUPPORTS (SEE ATTACHED FORM) AND SIGN THAT I REVIEWED
THE LIST __________
_________
Initials of Responsible
Date
Party
CHOICE OF SERVICE, PROVIDER or SELF-DIRECTED SUPPORTS (SEE ATTACHED FORM)
Service Choice (List all Services)
Name of Provider or Self-Directed chosen from attached list
Additional Choices can be added to Supplemental Page
I CERTIFY THAT I HAVE CHOSEN THE ABOVE SERVICES AND PROGRAMS
_____________________________________________________
Signature of Responsible Party
Date
I CERTIFY THAT I HAVE CHOSEN TO SELF-DIRECT MY SERVICES AND/OR HAVE CHOSEN THE ABOVE LISTED
QUALIFIED WAIVER SERVICES PROVIDERS (IF APPLICABLE)
_________________________________________________
_____ Not Applicable
Signature of Responsible Party
Date
DISTRIBUTION: Copy for the INDIVIDUAL/PARENT/GUARDIAN/DESIGNATED REPRESENTATIVE and copy for TCM
Provider
Revised 8/7/2013
STATE OF MISSOURI
DEPARTMENT OF MENTAL HEALTH
DIVISION OF DEVELOPMENTAL DISABILITIES
MEDICAID WAIVER, PROVIDER, AND SERVICES CHOICE STATEMENT
INDIVIDUAL NAME
DATE OF BIRTH
MEDICAID NUMBER
DMH ID NUMBER
Choice to Participate in a Division of Developmental Disabilities Waiver
As an alternative to placement in a long term care facility known as an Intermediate Care Facility for Mental Retardation (ICF/MR),
you have been recommended for participation in the following Division of Developmental Disabilities Medicaid Home and
Community-Based Waiver program:
[ ] Comprehensive Waiver [ ] Community Support Waiver [ ] Sara Jian Lopez Waiver [ ] Autism Waiver
[ ] Partnership for Hope Waiver
You may request services through this Medicaid Home and Community-Based Waiver, or you may request referral to an ICF/MR
facility. Please indicate your choice of the following services:
I wish to participate in the Medicaid Home and Community Based Waiver program specified above. I understand that
participation is conditional based on my eligibility for Medicaid and other criteria.
I wish to be referred to an ICF/MR facility.
I HAVE RECEIVED INFORMATION REGARDING THE OPTION TO SELF-DIRECT MY SERVICES’ AS WELL AS
INFORMATION FOR QUALIFIED AGENCY SUPPORTS (SEE ATTACHED FORM) AND SIGN THAT I REVIEWED
THE LIST __________
_________
Initials of Responsible
Date
Party
CHOICE OF SERVICE, PROVIDER or SELF-DIRECTED SUPPORTS (SEE ATTACHED FORM)
Service Choice (List all Services)
Name of Provider or Self-Directed chosen from attached list
Additional Choices can be added to Supplemental Page
I CERTIFY THAT I HAVE CHOSEN THE ABOVE SERVICES AND PROGRAMS
_____________________________________________________
Signature of Responsible Party
Date
I CERTIFY THAT I HAVE CHOSEN TO SELF-DIRECT MY SERVICES AND/OR HAVE CHOSEN THE ABOVE LISTED
QUALIFIED WAIVER SERVICES PROVIDERS (IF APPLICABLE)
_________________________________________________
_____ Not Applicable
Signature of Responsible Party
Date
DISTRIBUTION: Copy for the INDIVIDUAL/PARENT/GUARDIAN/DESIGNATED REPRESENTATIVE and copy for TCM
Provider
Revised 8/7/2013
STATE OF MISSOURI
DEPARTMENT OF MENTAL HEALTH
DIVISION OF DEVELOPMENTAL DISABILITIES
MEDICAID WAIVER, PROVIDER, AND SERVICES CHOICE STATEMENT
(Supplemental Page)
INDIVIDUAL NAME
DMH ID
CHOICE OF SERVICE, PROVIDER or SELF-DIRECTED SUPPORTS
This page is used only when:
1) Additional space is needed to list service choices in new waiver or
2) When the individual, guardian and/or designated representative choose a new service and/ or new provider
(changes providers) and/or choose to start self-directing supports
[ ] 1) Supplemental Page for Initial enrollment of waiver
[ ] 2) Supplemental Page for change of service or provider, or change to self-directed supports
Effective date:
I HAVE RECEIVED INFORMATION REGARDING THE OPTION TO SELF-DIRECT MY SERVICES’ AS WELL AS
INFORMATION FOR QUALIFIED AGENCY SUPPORTS (SEE ATTACHED FORM) AND SIGN THAT I REVIEWED
THE LIST __________
_________
Initials of Responsible
Date
Party
CHOICE OF SERVICE, PROVIDER or SELF-DIRECTED SUPPORTS (SEE ATTACHED FORM)
Service Choice (List all Services)
Name of Provider or Self-Directed chosen from attached list
I CERTIFY THAT I HAVE CHOSEN THE ABOVE SERVICES
_____________________________________________________
Signature of Responsible Party
Date
I CERTIFY THAT I HAVE CHOSEN TO SELF-DIRECT MY SERVICES AND/OR HAVE CHOSEN THE ABOVE LISTED
QUALIFIED WAIVER SERVICES PROVIDERS (IF APPLICABLE)
_________________________________________________
_____ Not Applicable
Signature of Responsible Party
Date
DISTRIBUTION: Copy for the INDIVIDUAL/PARENT/GUARDIAN/DESIGNATED REPRESENTATIVE and copy for TCM
Provider
Revised 8/7/2013
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