Section XI: Appendix and Forms
- Appendix A - G Forms (Complete Set) (PDF, 2.21MB, 196pg.)
- Appendix A (PDF, 105KB, 5pg.)
- A.1 - Employee Verification of Qualifications (PDF, 22KB, 1pg.)
- A.2 - Provider Agreement (PDF, 42KB, 4pg.)
- Appendix B - Regional Resource Development Center (RRDC) Forms (PDF, 1.2MB, 44pg.)
- B.1 - Referral (PDF, 50KB, 4pg.)
- B.2 - Intake (PDF, 59KB, 6pg.)
- B.3 - Initial Applicant Interview Acknowledgement (PDF, 20KB, 1pg.)
- B.4 - Freedom of Choice (PDF, 19KB, 1pg.)
- B.5 - Service Coordinator Selection (PDF, 22KB, 1pg.)
- B.6 - Application for Participation (PDF, 23KB, 1pg.)
- B.7 - Letter of Introduction to Local District of Social Services (LDSS) (PDF, 23KB, 1pg.)
- B.8 - Waiver Service Provider Interview (PDF, 69KB, 9pg.)
- B.9 - RRDC Quarterly Report (not yet available) (PDF, 0KB, 0pg.)
- B.10 - RRDS Application Packet Review (PDF, 89KB, 7pg.)
- B.11 - RRDS Revised Service Plan Review (PDF, 83KB, 7pg.)
- B.12 - RRDS Addendum Review (PDF, 43KB, 3pg.)
- B.13 - RRDS Late ISR Notification (PDF, 18KB, 1pg.)
- B.14 - RRDS Late RSP Notification (PDF, 18KB, 1pg.)
- B.15 - Change of Service Coordination Request (PDF, 33KB, 1pg.)
- Notice of Decision Forms (PDF, 496KB, 20pg.)
- NOD.1 - Authorization (PDF, 67KB, 2pg.)
- NOD.2 - Denial of Waiver Program (PDF, 64KB, 2pg.)
- NOD.3 - Intent to Discontinue from the Waiver Program (1) (PDF, 71KB, 3pg.)
- NOD.4 - Intent to Discontinue from the Waiver Program (2) (PDF, 102KB, 3pg.)
- NOD.5 - Reduction and/or Discontinuation of Waiver Service(s) (PDF, 78KB, 3pg.)
- NOD.6 - Increase and/or Addition of Waiver Service(s) (PDF, 40KB, 2pg.)
- NOD.7 - Suspension (PDF, 94KB, 2pg.)
- NOD.8 - Denial of Waiver Service and/or Denial of a Waiver Provider (PDF, 66KB, 2pg.)
- NOD.9 - Notification of Death of a Waiver Participant to LDSS (PDF, 23KB, 1pg.)
- Appendix C - Service Plan Forms (PDF, 2.1MB, 83pg.)
- C.1 - Initial Service Plan (PDF, 165KB, 26pg.)
- C.2 - Provider Selection (PDF, 22KB, 1pg.)
- C.3 - Initial Insurance Resource and Funding Information Sheet (PDF, 40KB, 3pg.)
- C.4 - Plan of Protective Oversight (PPO) (PDF, 54KB, 5pg.)
- C.5 - Waiver Participant's Rights and Responsibilities (PDF, 40KB, 3pg.)
- C.6 - Waiver Contact List (PDF, 28KB, 2pg.)
- C.7 - Moving Assistance Description and Cost Projection (PDF, 24KB, 1pg.)
- C.8 - Assistive Technology Description and Cost Projection (PDF, 24KB, 1pg.)
- C.9 - Community Transitional Services (CTS) Description and Cost Projection (PDF, 34KB, 3pg.)
- C.10 - Environmental Modification Description and Cost Projection (PDF, 22KB, 1pg.)
- C.11 - Waiver Services Final Cost (PDF, 20KB, 1pg.)
- C.12 - RRDS Approval of Final Cost (PDF, 48KB, 1pg.)
- C.13 - Revised Service Plan (PDF, 154KB, 19pg.)
- C.14 - Revised Insurance Resource and Funding Information Sheet (PDF, 43KB, 3pg.)
- C.15 - Addendum (PDF, 77KB, 7pg.)
- C.16 - Individual Service Reports (ISR) (PDF, 22KB, 2pg.)
- C.17 - Team Meeting Summary (PDF, 28KB, 3pg.)
- C.18 - Change of Provider Request (PDF, 29KB, 1pg.)
- Appendix D - Quality Management Specialist (QMS) Forms (PDF, 26KB, 2pg.)
- D.1 - Service Plan Review (PDF, 26KB, 2pg.)
- D.2 - Random Retrospective Review (not yet available) (PDF, 0KB, 0pg.)
- D.3 - Participant Satisfaction Survey (not yet available) (PDF, 0KB, 0pg.)
- D.4 - QMS Quarterly Report (not yet available) (PDF, 0KB, 0pg.)
- Appendix E - Serious Reportable Incident Forms (PDF, 318KB, 10pg.)
- SRI.1 - Initial Report (PDF, 82KB, 1pg.)
- SRI.2 - 24-Hour Provider Report (PDF, 37KB, 3pg.)
- SRI.2b - Service Coordinator 24-Hour Notification Report (PDF, 25KB, 1pg.)
- SRI.3 - QMS Initial Response (PDF, 24KB, 1pg.)
- SRI.4 - Provider Follow-Up Report (PDF, 23KB, 2pg.)
- SRI.5 - QMS Status Report (PDF, 22KB, 1pg.)
- SRI.6 - QMS Post-Investigation Follow-Up Contact with Participant (PDF, 21KB, 1pg.)
- Appendix F - Other forms (PDF, 944KB, 22pg.)
- *Hospital and Community Patient Review Instrument (HC/PRI) (PDF, 42KB, 4pg.)
- *DSS-3139 Home Assessment Abstract (PDF, 138KB, 6pg.)
- *Instructions for Home Assessment Abstract (PDF, 64KB, 10pg.)
- *NYS Health Department Numerical Standards Master Sheet (PDF, 72KB, 2pg.)
- Appendix G - RRDC, QMS, and WMS Contact Lists (PDF, 57KB, 3pg.)