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Form Dmas-305 - Request For Screening For Individual And Family Developmental Disabilities Support Waiver (Dd Waiver)

REQUEST FOR SCREENING FOR

INDIVIDUAL AND FAMILY DEVELOPMENTAL DISABILITIES SUPPORT WAIVER

(DD WAIVER)

This is a request to be screened for the Individual and Family Developmental Disabilities

Support Waiver. Submission of this request form does not guarantee admission into the waiver,

nor does it guarantee Medicaid eligibility. Complete the form in its entirety and mail to the

Screening Facility (Child Development Clinic or Health Department) closest to your area.

Name of parent or responsible party (please PRINT):____________________________________

Home phone

_____________________Work/Cell phone:____________________

(with area code):

Name of person to be screened (Print):_________________________________________________

Last

First

Check one: ___Male

___Female

Date of application:_____________________

Address: ________________________________________________________________________

Street Address

__________________________________________________________________________

City

State

Zip

County (if applicable): ___________________________

*Date of birth: _______________Age: _____ Social Security Number:_____________________

*Individuals must be 6 years of age or older and cannot have a diagnosis of Mental Retardation to

be eligible for this waiver.

Are you currently Medicaid eligible?

___ Yes

___No

•

If yes, please provide 12 digit Medicaid number:_____________________________________

•

What services are you currently receiving under Medicaid?___________________________

_________________________________________________________________________________

Signature of Person making request for screening:______________________________________

Name of Person making request (PRINT): _____________________________________________

Relationship to Person to be screened:_________________________________________________

Phone Number of Person making request (if different from above): ________________________

Completed applications must be submitted to the Screening facility closest to your home.

Forms sent to DMAS will not be processed.

FOR SCREENING TEAM USE ONLY

Date Application Received: ___/___/___

Signature of Receiver:_____________________________

Date(s) Contact Made With Applicant:_______________________________________

Date Screening Performed: ___/___/___

Service Approved?

If Approved, which service?

ICF/MR

DD Waiver

Service Not Approved?

If Not Approved, Reason:____________________________

Date Applicant Notified: ___/___/___ (Attach copy of letter to this request)

DMAS 305 Updated 03/04/2009

Form Dmas-305 - Request For Screening For Individual And Family Developmental Disabilities Support Waiver (Dd Waiver)

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