February 05, 2025 Waiver Forms and Instructions

Baton Rouge, Louisiana, Feb 05, 2025 - The following are forms and instructions for the Community Choices Waiver (CCW) and the Adult Day Health Care (ADHC) Waiver.

• Adult Day Health Care (ADHC) Waiver Home Delivered Meals Policy (PHE)
• Assistive Devices and Medical Supplies Form
• Assistive Technology (AT) Form
• Assistive Technology (AT) Policy
• Back-Up Staffing Plan
• CCW PAS DSW/Participant Relationships and Living Arrangements Guidance
• CCW Service Logs and Instructions
• Change In Status Screening & Decision Making Tool
• Clinical Assessment Protocols Summary (CAPS)
• Clinical Assessment Protocols Summary (CAPS) Instructions
• Confidentiality Consent for Shared PAS and LT-PCS
• Data Management Contractor Problem Sheet Procedure
• Declining ADHC Waiver Offer
• Declining Current ADHC Waiver Services
• Declining CCW Offer
• Declining Current CCW Services
• e148-W Instructions
• EAA Landlord Permission
• Emergency Plan
• Environmental Accessibility Adaptation Form
• Evacuation Tracking Form
• Flexible Schedule/Budget Worksheet
• Have You Heard? Assistive Technology
• Have You Heard? Medically Tailored Meals/Nutritional Counseling
• iHC Correction Request Form
• Individual Responsibility Agreement Form
• Level of Care/Plan of Care Review Checklist
• Major Medical Event (MME) Flowchart
• Medically Tailored Meals (MTMs) / Nutritional Counseling (NC) Referral Form
• Medically Tailored Meals (MTMs) / Nutritional Counseling (NC) Policy
• Monitored In-Home Caregiving (MIHC) Back-Up Staffing Plan
• Monitored In-Home Caregiving (MIHC) Fact Sheet
• Monitored In-Home Caregiving (MIHC) Services Form
• Nursing Therapy Evaluation Form
• Nursing Therapy Evaluation Referral Form
• Nursing Therapy Evaluation Referral Form Instructions
• Nursing Therapy Payment Authorization Form
• Request for Payment Override Form and Instructions
• Restraints Factsheet
• Rights and Responsibilities for Applicants/Participants for Waivers
• SCD Service Log Codes
• Self-Direction Self-Assessment
• Support Coordination Contact Documentation (Electronic form)
• Support Coordination Contact Documentation (Handwritten form)
• Support Coordination Contact Documentation (SCD) Instructions
• Support Coordination Transfer of Records Form 
• Transition Services Form
• Waiver Plan of Care (.pdf)
• Waiver Plan of Care (MS Word)