Fingerprint Submission Authorization Form Page 3
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3PROGRAM_CODE
PROGRAM_NAME
Community Residence Part 671 – Residential Habilitation
0053
0060
Crisis Intervention
0070
Summer Camp
0080
Residential School
0090
Intermediate Care Facility (30 beds or less)
TUBS – Intermediate Care Facility (30 beds or less)
0091
0100
Clinic Treatment Facility (Free-Standing Clinic)
0101
Clinic Treatment Facility (Clinic Joint Venture)
0120
Specialty Clinic
0150
Family Support Services
0190
Program Development Grants
0200
Day Treatment
0202
Day Treatment Partial
0212
HCBS Day Habilitation Service
0213
HCBS Prevocational Services
0214
HCBS Supported Employment
0215
HCBS Environmental Modifications
0216
HCBS Adaptive Technologies
0219
HCBS Residential Habilitation Service (At home)
0220
HCBS Residential Habilitation Service (Family Care)
0221
HCBS Assistive Supports
0222
Other Service Coordination (Non-Medicaid)
0229
Medicaid Service Coordination (MSC)
0231
HCBS Supervised IRA (Room & Board & Residential Habitation Services
0232
HCBS Supportive IRA (Room & Board & Residential Habitation Services
0233
HCBS Freestanding Respite
0235
HCBS Hourly Respite
0330
Day Training
0340
Sheltered Workshop/Certified Work Activity
0360
Classroom Education
0370
Preschool Program
0380
Transitional Employment Placement
0390
Supported Employment (non-HCBS waiver)
0400
Prevocational (non-HCBS waiver)
0410
Individualized Support Services
0411
HCBS Consolidated Supports and Services
0413
HCBS Family Education and Training
0414
Epilepsy Services
0416
HCBS Waiver Plan of Care Support Services
0610
Recreation
0630
Homemaker/Housekeeping Services
0650
Respite Care
*0670
Transportation
0750
Information and Referral
0810
Case Management
*0880
Subcontract Service
(Program Type for Registered Provider)
0890
Local Governmental Unit (LGU) Administration
Community Residence Part 671 Supportive –Residential Habitation
1053
1090
Intermediate Care Facility (over 30 beds)
1150
Traumatic Brain Injury (TBI)
1190
Special Legislative Grants
HCBS Care at Home –III
1220
1670
Integrated Employment Transportation
1850
Voluntary Preservation Project
2090
VOICF/DD, Sheltered Workshop
2091
VOICF/DD, Sheltered Workshop (not operated by service provider)
2190
Developmental Disabilities Program Council Grants
HCBS Care at Home – IV &VI
2220
3070
Shelter Plus Care Housing
3090
VOICF/DD, School District Contract
4090
SOICF Sheltered Workshop/Day Training
5090
VOICF/DD Day Training
5091
VOICF/DD Day Training (not operated by a service provider)
6090
Day Program Service Included in ICF/DD (On-site)
6091
Day Program Services Included in ICF/DD (Off-site)
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