Community Pathways Waiver Enrollment Checklist
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1COMMUNITY PATHWAYS WAIVER ENROLLMENT CHECKLIST
INDIVIDUAL’S NAME: ______________________________________________________________ (FIRST, MIDDLE, LAST)
Current address: ____________________________________________________________________ County: _______________
________________________________________________
Zip Code: ___________
DDA FUNDING CATEGORY GROUP
(CHECK ALL THAT APPLY)
Transitioning Youth – Fiscal Year __________
Crisis Resolution/Emergency
Currently receiving State only funding (Conversion)
Waiting List Equity Fund (WLEF)
Money Follows the Person (MFP)
Placement from an SRC/SETT/Nursing or State Hospital Facility
Facility Name: _______________________________________________ Discharge Date: ____________________
WAIVER SERVICE REQUESTED:
(CHECK ALL THAT APPLY)
Assistive Technology & Adaptive
Environmental Accessibility
Support Brokerage
Equipment
Adaptations
Behavioral Supports
Environmental Assessments
Supported Employment
Family and Individual Support
Community Learning Service
Transition Services
Services
Community Residential Habilitation
Live-In Caregiver Rent
Transportation
Community Supported Living
Medical Day Care
Vehicle Modifications
Arrangement/Personal Supports
Day Habilitation
Respite
Employment Discovery &
Shared Living
Customization
(formerly Individual Family Care)
DOCUMENTS:
√
Document Name
Date Completed
Medicaid Application (Long or Short Form)
Level of Care – Initial Certificate of Need
Freedom of Choice Form (WC-3B)
Individual Plan (IP) – Traditional Model:
The most recent IP (Initial or Annual)
Individual Plan (IP) – Self-Directed Model: IP and Self-Directed Budget
Waiver meeting minutes and sign in sheet.
For Regional Office Use Only
√
Document Name
Date Completed
Service Funding Plan (SFP) with Regional Office Sign-Off
Resource Coordinator (printed name):
Resource Coordination Agency (printed name):
Office Address: ___________________________________________________________________________
Email Address: ___________________________________________________________________________
Phone: ______________________________
Fax: ________________________________
Resource Coordinator (signature): _______________________________________ Date: ______________
DDA Regional Waiver Coordinator: ______________________________________ Date: ______________
CP Waiver Enrollment Checklist
Revised August 2014
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