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OLTL Service Authorization Form HCBS Waiver Programs DATE New referral Temporary change Revision change in need CONSUMER S NAME DOB ADDRESS PHONE/EMAIL PRIMARY CONTACT RELATIONSHIP TO CONSUMER Termination PRIMARY CARE PHYSICIAN ICD-9 DIAGNOSIS CODE MEDICAL ASSISTANCE NUMBER 10 DIGITS PROVIDER NAME PROGRAM NAME OBRA Waiver Independence Waiver CommCare Waiver Attendant Care/Act 150 Aging Waiver AIDS Waiver SERVICE AUTHORIZED TYPE Accessibility adaptations Non-medical transportation Physical therapy-assist. Adult daily living Nursing LPN Prevocational services Behavior therapy Residential habilitation Cognitive rehabilitation Nutritional counseling Respite agency Community integration Occupational therapy Service coordination Community transition services Speech and language therapy Counseling services Personal assistance services agency Structured day habilitation Durable medical equipment supplies Supported employment Home delivered meals Personal emergency response system PERS Transiti....

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232