Form I/DD-1 "I/DD Medicaid Waiver Individual Choice" - Kansas

What Is Form I/DD-1?

This is a legal form that was released by the Kansas Department for Aging and Disability Services - a government authority operating within Kansas. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 20, 2019;
  • The latest edition provided by the Kansas Department for Aging and Disability Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form I/DD-1 by clicking the link below or browse more documents and templates provided by the Kansas Department for Aging and Disability Services.

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Download Form I/DD-1 "I/DD Medicaid Waiver Individual Choice" - Kansas

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I/DD-1
Revised 5/20/2019
HOME AND COMMUNITY BASED
SERVICES I/DD MEDICAID WAIVER
INDIVIDUAL CHOICE
Name of Participant
Date of Birth
If assessment results indicate that I meet functional eligibility criteria qualifying me for long-term
care services that are essential to my health and welfare, I have two choices on where to receive
my services. My choices are to receive services in my home or other community-based setting,
within cost limitations of the program, or in the institutional equivalent (ICF-IID). I have been
informed if I am determined eligible for Home and Community-Based Services (HCBS), I have
the option to remain in the community and receive the services designated on my Person-Centered
Service Plan.
My initials mean I understand that I am not guaranteed to receive either choice and
may be placed on a waiting list, depending upon the availability of either service.
It is my choice to:
Apply for ICF/IID facility placement
Receive HCBS under the Intellectual/Developmental Disability
(I/DD) Medicaid waiver when offered.
·
My signature verifies I have
read,
or had read to
me,
my rights and responsibilities and have made
the choices as indicated. I am also indicating willingness to participate in the design of my
Person-Centered Service
Plan.
__________________________________________________________________________________________
Participant Signature
Date
___________________________________________________________________________
Date
Guardian Signature
___________________________________________________________________________
CDDO Member Signature
Date
I/DD-1
Revised 5/20/2019
HOME AND COMMUNITY BASED
SERVICES I/DD MEDICAID WAIVER
INDIVIDUAL CHOICE
Name of Participant
Date of Birth
If assessment results indicate that I meet functional eligibility criteria qualifying me for long-term
care services that are essential to my health and welfare, I have two choices on where to receive
my services. My choices are to receive services in my home or other community-based setting,
within cost limitations of the program, or in the institutional equivalent (ICF-IID). I have been
informed if I am determined eligible for Home and Community-Based Services (HCBS), I have
the option to remain in the community and receive the services designated on my Person-Centered
Service Plan.
My initials mean I understand that I am not guaranteed to receive either choice and
may be placed on a waiting list, depending upon the availability of either service.
It is my choice to:
Apply for ICF/IID facility placement
Receive HCBS under the Intellectual/Developmental Disability
(I/DD) Medicaid waiver when offered.
·
My signature verifies I have
read,
or had read to
me,
my rights and responsibilities and have made
the choices as indicated. I am also indicating willingness to participate in the design of my
Person-Centered Service
Plan.
__________________________________________________________________________________________
Participant Signature
Date
___________________________________________________________________________
Date
Guardian Signature
___________________________________________________________________________
CDDO Member Signature
Date