(Revised 4/1/07 ML #3077)
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Purpose:
This form is completed to obtain verification that an individual is eligible for Attendant Care Services and has identified eligible providers and a contingency plan.
When Prepared:
The Request for Attendant Care Services is completed when an individual request to receive Attendant Care Services and completed on an annual basis or as changes are identified.
By Whom Prepared:
The clients HCBS Case Manager along with the applicant will complete the form.
Demographic Information:
The HCBS Case Manager completes the applicants name, address, telephone number, email, Medicaid number and date of birth.
Applicant Certifications:
The applicant checks the appropriate boxes and signs and dates the verifications.
Primary Care Physician Certifications:
The form is sent to the individual’s primary care physician who checks the appropriate boxes and signs and dates the verifications.
A letter from the primary care physician can replace this section if it includes all the components of this section and is also signed and dated by the physician.
Providers, Attendant Care Service Providers, and Contingency Care Providers:
These sections are completed by the applicant and HCBS Case Manager.
Number of Copies and Distribution:
The original is filed in the applicant's/client's case record. One copy is provided to the applicant/client when completed. One copy included in the application packet provided to the Assistant Medical Director or HCBS Program Administrator and is used in determining approval or continued approval for the service.
This form is available through the state e-forms or by contacting the HCBS Program Administrator.