Form Dhmh Dd Wc12-A - Traditional Service Model Reporting Form - Developmental Disabilities Administration
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1DEVELOPMENTAL DISABILITIES ADMINISTRATION
COMMUNITY PATHWAYS WAIVER – Traditional Service Model
Reporting Form
TO: Terri Hartman
DDA Waiver Unit
th
201 W. Preston Street, 4
Floor
Baltimore, Maryland 21201
Phone: (410) 767-5421
FAX: (410) 767-5850
Email:
Waiver.DDA@maryland.gov
INDIVIDUAL INFORMATION:
_________________________________
_____________________________
_______________
Last Name
First Name
Middle Name/Initial
__________________________________
________________________ _________________________________
Medical Assistance Number
Social Security Number
Jurisdiction/County
□
Remains with _________________________ or ______________________ with a change of site address:
(Residential Provider)
(Day Provider)
Address: ______________________________________________ City: ______________________ Zip Code: _________
Date of Change: ________________________
Jurisdiction/County: _________________________
□
Effective ______________ (Date) has had a change in waiver service:
From ___________________________ to ____________________________
(Please write provider/address change above.)
(Type of Service)
(Type of Service)
Examples: Residential Habilitation to Personal Supports; Supported Employment to Day Habilitation; FISS to Personal Supports
□
Has moved from _________________________ and/or _________________________to a new waiver provider:
(
Residential Provider)
(Day Provider)
Provider: ______________________________________________________
Site Address: _________________________________________ City: ___________________ Zip Code: ________
Date of Change: ________________________
Jurisdiction/County: _________________________
□
Has had a change in Resource Coordination Agency from _____________________________________________ to
______________________________________________________, ____________________________________
(Resource Coordination Agency)
(Address)
□
Has been admitted to:
□
Nursing Facility: _____________________________________________ Admission Date: __________ Time: ________
(Name of Facility)
Discharge Date: ___________ Time: ________
□
Chronic Rehabilitation Facility: __________________________________ Admission Date: __________ Time: ________
(Name of Facility)
Discharge Date: __________ Time: ________
□
Other: _________________________________________________________ Admission Date: __________ Time: ________
(Name)
Discharge Date: __________ Time: ________
______________________________________
___________________________________
______________
Completed By
Agency
Date
DHMH DD WC12-A-Traditional
Revised: November 5, 2014
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