Exception Request Form for Aged and Disabled Waiver and State Plan Personal Care Services Participants - Residential Assisted Living Facilities (Ralfs) or Certified Family Homes (Cfhs) - Idaho

This "Exception Request Form for Aged and Disabled Waiver and State Plan Personal Care Services Participants - Residential Assisted Living Facilities (Ralfs) or Certified Family Homes (Cfhs)" is a Idaho-specific form released by the Idaho Department of Health and Welfare on December 1, 2016.

Download the form by clicking the link below, fill it out by hand, and mail it as per the guidelines provided by the department or the applicable legal instructions.

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RESIDENTIAL ASSISTED LIVING FACILITIES (RALFS) OR CERTIFIED FAMILY HOMES (CFHS)
Exception Request Form for Aged and Disabled Waiver and State Plan Personal Care Services Participants
Provider:
Participant Name:
Participant MID:
Setting Quality that
Requires Exception
Assessed Needs
A&D and PCS Exception Request Form - Revised 12/2016 V1.0
Page 1 of 4
RESIDENTIAL ASSISTED LIVING FACILITIES (RALFS) OR CERTIFIED FAMILY HOMES (CFHS)
Exception Request Form for Aged and Disabled Waiver and State Plan Personal Care Services Participants
Provider:
Participant Name:
Participant MID:
Setting Quality that
Requires Exception
Assessed Needs
A&D and PCS Exception Request Form - Revised 12/2016 V1.0
Page 1 of 4
Prior Interventions
and Supports
Prior Methods
Intervention
Description
A&D and PCS Exception Request Form - Revised 12/2016
Page 2 of 4
Data Collection
Time Limit
My signature on this form indicates that I am aware of and agree with exception outlined on this form. I was
provided with the information I needed to make an informed decision about this exception.
Participant Information
Name:
Date:
Participant Signature:
Legal Guardian (if applicable)
Name:
Date:
Legal Guardian Signature:
Address:
City, State, Zip:
Phone:
Alternate Phone:
A&D and PCS Exception Request Form - Revised 12/2016
Page 3 of 4
My signature on this form indicates that I am aware of and agree with the risks outlined on this form. I am
responsible for implementing this exception as documented. My signature assures that no harm will come to
the participant based on the interventions and supports used for the exception.
Agency Information
Name of Agency:
Date:
Agency Signature:
For Department use only
☐ Approved
____________________
____________
☐ Denied
Authorizing Signature
Date
Comments:
A&D and PCS Exception Request Form - Revised 12/2016
Page 4 of 4

Download Exception Request Form for Aged and Disabled Waiver and State Plan Personal Care Services Participants - Residential Assisted Living Facilities (Ralfs) or Certified Family Homes (Cfhs) - Idaho

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