Developmental Disabilities Administration



Developmental Disabilities Administration (DDA)Modified Service Funding Plan RequestRequest Urgency: FORMCHECKBOX Immediate Need FORMCHECKBOX Standard FORMCHECKBOX Cost Neutral Type of Modified Service Funding Plan Request:Provider Initiated: FORMCHECKBOX Reduction FORMCHECKBOX Site Change FORMCHECKBOX Existing Service Adjustment (Continuation of time-limited service; recurring add-on; increase in existing service)Coordinator of Community Services Initiated: FORMCHECKBOX New Service (New add-on or additional service) FORMCHECKBOX Provider Change FORMCHECKBOX Service Change (one service to another)Date of Request: FORMTEXT ????? Annual IP Meeting Date: FORMTEXT ?????Name: FORMTEXT ????? Date of Birth: FORMTEXT ?????Address: FORMTEXT ?????Phone: FORMTEXT ?????Email: FORMTEXT ?????SS#: FORMTEXT ?????MA#: FORMTEXT ?????Individual’s preferred method of communication: FORMCHECKBOX Email FORMCHECKBOX Letter FORMCHECKBOX Telephone FORMCHECKBOX Other: FORMTEXT ?????PART I: RequestDDA Program (check one): FORMCHECKBOX Community Pathways Traditional Waiver FORMCHECKBOX Community Pathways Self-Directed Waiver FORMCHECKBOX State Funded Program-DD FORMCHECKBOX State Funded Program-Supports OnlyIs the service requested a waiver service? FORMCHECKBOX YES FORMCHECKBOX NOCoordinator of Community Service (CCS) Name / Phone: FORMTEXT ?????Person submitting form (if not CCS) Name / Phone: FORMTEXT ?????Team Meeting Consensus (Required)Team Meeting Date: FORMTEXT ?????Does the team have consensus related to this request? FORMCHECKBOX YES FORMCHECKBOX NOIf “No” has request for mediation been submitted to Regional Office? FORMCHECKBOX Yes: ( FORMTEXT / / ) FORMCHECKBOX No: Explain: FORMTEXT ????? IP Addendum or Revised IP Attached (Required) FORMCHECKBOX Part 1A: Desired Outcome FORMTEXT ????? Part 1B: Current DDA Authorized Services (From PCIS2–including add-ons):ServiceScopeFrequencyDuration FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Part 1C: Current State Services, Medicaid Services and Natural Supports (CFC, REM, MA State Plan, etc.) FORMTEXT ????? Part 1D: Other Services Explored to Meet Desired Outcome What other resources/services/strategies have been explored ( i.e., health insurance, generic services) and the result of referrals. Add pages if needed. FORMTEXT ????? Part 1E: Services - Check service change needed to achieve desired outcome (add pages as needed):CurrentRequestedService FORMCHECKBOX FORMCHECKBOX Assistive Technology & Adaptive Equipment FORMCHECKBOX FORMCHECKBOX Community Learning Services FORMCHECKBOX FORMCHECKBOX Day Habilitation FORMCHECKBOX FORMCHECKBOX Employment Discovery and Customization FORMCHECKBOX FORMCHECKBOX Environmental Accessibility Adaptations FORMCHECKBOX FORMCHECKBOX Family Support Services (FSS) FORMCHECKBOX FORMCHECKBOX Fiscal Management Services FORMCHECKBOX FORMCHECKBOX Individual Support Services (ISS) FORMCHECKBOX FORMCHECKBOX Live-In Caregiver Rent FORMCHECKBOX FORMCHECKBOX Other / specify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX Personal Supports FORMCHECKBOX FORMCHECKBOX Residential Habilitation FORMCHECKBOX FORMCHECKBOX Respite Care Services FORMCHECKBOX FORMCHECKBOX Self-Directed FORMCHECKBOX FORMCHECKBOX Shared Living FORMCHECKBOX FORMCHECKBOX Support Broker FORMCHECKBOX FORMCHECKBOX Supported Employment FORMCHECKBOX FORMCHECKBOX Transition Services-Community Exploration FORMCHECKBOX FORMCHECKBOX Transition Services-Residential Set Up FORMCHECKBOX FORMCHECKBOX TransportationPart 1F: Specific Description of Proposed Services: (Use the space below or include attachment). FORMTEXT ????? Projected length of service need: FORMCHECKBOX ( FORMTEXT ???) week(s) FORMCHECKBOX 1 month FORMCHECKBOX 3 month FORMCHECKBOX 6 month FORMCHECKBOX Ongoing FORMCHECKBOX Other: FORMTEXT ?????Projected Start Date: FORMTEXT ?????Part 1G: Justification and Documentation:Describe the individual’s current status and reason for new or additional service, including reasons such as health and safety, community integration or increased independence. Attach supporting documentation if applicable. If there has been a change in the individual’s current situation that effects their health and safety, level of community integration, or independence, please note. FORMTEXT ?????Documentation Provided – Check all that apply: FORMCHECKBOX Team Meeting Notes FORMCHECKBOX Evidence of Charges against Caregiver FORMCHECKBOX Physician Orders FORMCHECKBOX Police Report FORMCHECKBOX Medical Assessment/Evaluation FORMCHECKBOX Behavioral Data - Summarized FORMCHECKBOX Hospital Discharge Summary FORMCHECKBOX Sleep Chart FORMCHECKBOX Summary of Nursing 45 Day Review FORMCHECKBOX DORS Report FORMCHECKBOX Health Risk Screening Tool (HRST) FORMCHECKBOX Acceptance/Denial Letters FORMCHECKBOX Social Services Report (i.e. APS) FORMCHECKBOX Eviction Notice FORMCHECKBOX Coordinator of Community Service Assessment FORMCHECKBOX Risk Assessment FORMCHECKBOX DDA/OHCQ Report FORMCHECKBOX Supports Intensity Scale? (SIS?) FORMCHECKBOX Other: FORMTEXT ?????Part 1H: Individual Choice: At times team members and family members may ask for a more or less restrictive setting or other services than what the individual may want. Does this information and request reflect the individual’s choice and preference? FORMCHECKBOX YES FORMCHECKBOX NO - if no, please explain: FORMTEXT ?????Part 1G: Signatures for Modified Service Funding Plan RequestName(print)Relationship / AgencySignature*agree(please initial)*YES*NO1 Self2 3 4 5 6 78-14287551942900*My initials above indicate that I agree/ or disagree with the services that are outlined in this request; and I understand that, as a member of this team, I may request changes at any time.PART 2 REQUEST FOR FUNDINGPart 2A: Cost Detail - Complete Sheets for All Requested ServicesPart 2B: Signatures. (Please note: As plans progress through the negotiation and approval process, changes to the original proposal may occur. Final approval of all Service Funding Plans rests with the DDA Regional Director. Providers will receive an Award Letter from the DDA Deputy Secretary when the plan has been approved.)Person receiving services: (Signature indicates review of the Modified Service Funding Plan and attachments.)Date:Family/Guardian: (Signature indicates review of the Modified Service Funding Plan and attachments.)Date:Coordinator of Community Services: (Signature indicates review of the Modified Service Funding Plan and attachments.)Date:Provider: (Signature indicates that the information presented in the Modified Service Funding Plan and attachments is accurate and complete.)Date:Regional Program Staff: (Signature indicates that the regional program staff and provider have agreed upon the services to be funded.)Date:Regional Director: (Signature indicates regional approval of the Modified Service Funding Plan.)Date:Copies of the final approved version of this Service Funding Plan are available upon request. ................
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