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• Waiver Forms and Instructions

  Details:

  April 02, 2025

  • Aging Louisianans

  OAAS waiver forms and instructions to be used for OAAS Community Choices Waiver (CCW) and Adult Day Health Care (ADHC) Waiver programs.

  Downloadable Assets:

  Waiver Forms and Instructions Assistive Devices and Medical Supplies Form, OAAS-PF-16-001 Assistive Technology Form, OAAS-PF-23-002 Back-Up Staffing Plan, OAAS-PF-10-015 CCW Personal Assistance Services (PAS): DSW/Participant Relationship and Living Arrangements Guidance, OAAS-PC-16-001 CCW Service Log Instructions, OAAS-P-18-005 CCW PAS Service Log, OAAS-PF-11-015 Clinical Assessment Protocols Summary (CAPS), OAAS-PF-10-005 Clinical Assessment Protocols Summary (CAPS) Instructions, OAAS-PF-12-005 Release of Confidentiality for Shared PAS or Shared LT-PCS, OAAS-RF-11-016 Data Management Contractor (DMC) Problem Sheet Procedure, OAAS-ADM-11-020 Adult Day Health Care (ADHC) Waiver Offer Declination Form, OAAS-RF-09-004 Current ADHC Waiver Services Declination Form, OAAS-RF-09-006 Community Choices Waiver (CCW) Offer Declination Form, OAAS-RF-09-005 Current CCW Waiver Services Declination Form, OAAS-RF-09-007 148W - Notification of Admission, Status Change or Discharge for HCBS Waiver Instructions, OAAS-ADM-13-016 EAA Landlord Permission Letter, OAAS-RF-19-001 OAAS Emergency Plan, OAAS-PF-09-004 Environmental Accessibility Adaptation (EAA) Form, OAAS-PF-12-007 Flexible Schedule / Budget Worksheet, OAAS-PF-10-008 Have You Heard? Assistive Technology, OAAS-R-23-003 Have You Heard? Medically Tailored Meals & Nutritional Counseling, OAAS-R-23-002 interRAI HC (iHC) Assessment Corrections Request Form, OAAS-ADM-24-006 Individual Responsibility Agreement (IRA) Form, OAAS-RF-21-003 OAAS Level of Care/Plan of Care Review Checklist, OAAS-PF-12-008 Major Medical Event Flowchart for Support Coordinators, OAAS-PC-14-003 Medically Tailored Meals & Nutritional Counseling Referral Form, OAAS-PF-23-003 Monitored In-Home Caregiving (MIHC) Back-Up Staffing Plan, OAAS-PF-22-001 MIHC Fact Sheet for Support Coordinators, OAAS-PC-15-001 MIHC Services Form, OAAS-PF-15-006 CCW Nursing/Therapy Form, OAAS-PF-13-003 CCW Nursing/Therapy Evaluation Referral Form, OAAS-PF-13-004 CCW Nursing/Therapy Evaluation Referral Instructions, OAAS-PF-13-008 CCW Nursing/Therapy Payment Authorization, OAAS-PF-13-002 Request for Payment/Override Form and Instructions, OAAS-PF-08-014 Restraints Fact Sheet, OAAS-RC-14-002 HCBS Waivers - Rights and Responsibilities, OAAS-RF-10-005 SCD Service Log Codes, OAAS-SC-19-002 Self-Assessment for Self-Direction Option for CCW, OAAS-RF-12-005 SCD Electronic Form, OAAS-SC-19-004 SCD Form (Handwritten), OAAS-SC-19-004 SCD Instructions, OAAS-SC-19-003 Support Coordination Transfer of Records Form, OAAS-SC-18-004 Transition Services Form (TSF), OAAS-PF-07-010 OAAS Waiver Plan of Care (PDF), OAAS-PF-10-003 OAAS Waiver Plan of Care (Word), OAAS-PF-10-003 Abbreviated Support Coordination Documentation, OAAS-SC-24-017 Abbreviated SCD - Handwritten Abbreviated SCD Instructions, OAAS-SC-24-018