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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 Transition service coordination Home health aide Telecare Details of activities for these services are listed below. Must be accompanied by a script renewed every 60 days. For all participant-directed and Financial Management Services FMS please use the referral protocols established by the Vendor Fiscal/Employer Agent VF/EA. TOTAL NUMBER OF APPROVED UNITS PER WEEK AMOUNT SERVICE PROVISION DATES SERVICE BEGIN AND END DATES/APPLICABLE DATES PREFERRED SCHEDULE DURATION AND FREQUENCY DESIRED OUTCOME OF SERVICE SERVICE COORDINATOR SC SC AGENCY SPECIAL CONDITIONS/INSTRUCTIONS INDIVIDUALIZED BACKUP PLAN UNIQUE CIRCUMSTANCES ALLERGIES SMOKING/PETS CHILDREN UNDER 18 ETC. MA 560 6/13 Details of current needs The consumer will need assistance with the following ADL/IADLS SCOPE Bathing Hair care Dressing Lotion/ointment Meal preparation Eating/drinking Laundry Light housekeeping Shopping Medication management Reading/writing Managing finances Social/leisure activities Telephone/communication devices Securing transportation Appointment scheduling Caring for personal possessions Obtaining seasonal clothing Using a prosthetic device Ambulating Range of motion Supervised walks Supervision/coaching/cueing Toileting Bowel/bladder management Transfers Incontinence care Catheter care Wound care G-tube feedings Other. 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 Transition service coordination Home health aide Telecare Details of activities for these services are listed below. Must be accompanied by a script renewed every 60 days. For all participant-directed and Financial Management Services FMS please use the referral protocols established by the Vendor Fiscal/Employer Agent VF/EA.
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