DD Provider Training Waiver Request Form - Idaho

The Idaho Department of Health and Welfare has released this version of the "DD Provider Training Waiver Request Form" on January 1, 2014.

This form may be used by all Idaho residents: download the printable PDF by clicking the link below and use it according to the applicable legal guidelines.

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DD PROVIDER TRAINING WAIVER REQUEST
The Division of Medicaid may grant temporary approval to an individual caregiver who meets
all qualifications, EXCEPT for the required developmental disability training course, to become
a PCS provider to a developmentally disabled participant IF ALL of the following conditions are
met:
1. Medicaid has verified that there are no qualified providers reasonably available to
provide services to the client requesting the services;
2. The caregiver must be enrolled in the next available training course with a graduation
date no later than six (6) months from the date of the request for temporary status; and
3. The supervising QIDP makes MONTHLY visits until the caregiver successfully
completes the training program.
_________________________ __________________________________ ________________
PCS Provider
Address
Phone
Caregiver Name:_____________________________________________________
Enrolled in course: Yes
Start Date:____________ Instructor: _____________________
Anticipated Completion Date: _________________ Completion Date: _____________________
____________________________ _________________________________ ________________
Participant
Address
Phone
____________________________ _________________________________ ________________
QIDP
Address
Phone
________________________________________ _____________________ ________________
QIDP Signature
QIDP Provider #
Date
________________________________________
________________
PCS Provider Agency Signature
Date
NOTE:
Please complete and return to Medicaid for approval.
APPROVED: Yes
No
_______________________________ ________________
QI Specialist Signature
Date
DD Provider Training Waiver Request Form V1.0
1/2014 jb
DD PROVIDER TRAINING WAIVER REQUEST
The Division of Medicaid may grant temporary approval to an individual caregiver who meets
all qualifications, EXCEPT for the required developmental disability training course, to become
a PCS provider to a developmentally disabled participant IF ALL of the following conditions are
met:
1. Medicaid has verified that there are no qualified providers reasonably available to
provide services to the client requesting the services;
2. The caregiver must be enrolled in the next available training course with a graduation
date no later than six (6) months from the date of the request for temporary status; and
3. The supervising QIDP makes MONTHLY visits until the caregiver successfully
completes the training program.
_________________________ __________________________________ ________________
PCS Provider
Address
Phone
Caregiver Name:_____________________________________________________
Enrolled in course: Yes
Start Date:____________ Instructor: _____________________
Anticipated Completion Date: _________________ Completion Date: _____________________
____________________________ _________________________________ ________________
Participant
Address
Phone
____________________________ _________________________________ ________________
QIDP
Address
Phone
________________________________________ _____________________ ________________
QIDP Signature
QIDP Provider #
Date
________________________________________
________________
PCS Provider Agency Signature
Date
NOTE:
Please complete and return to Medicaid for approval.
APPROVED: Yes
No
_______________________________ ________________
QI Specialist Signature
Date
DD Provider Training Waiver Request Form V1.0
1/2014 jb

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