Wisconsin Hemophilia Home Care Program Application printable pdf download

Wisconsin Hemophilia Home Care Program Application

DEPARTMENT OF HEALTH SERVICES

STATE OF WISCONSIN

Division of Medicaid Services

42 CFR 431

F-22637 (03/2017)

INTERAGENCY NOTIFICATION

TERMINATION OF COMMUNITY WAIVER PARTICIPATION

This form is to be completed by the care manager/support and service coordinator and sent to the Income Maintenance

Worker (IMW) when the community waiver participant loses Medicaid community waiver eligibility.

NAME – Community Waiver Care Manager/Support and Service Coordinator

Agency

NAME – Income Maintenance Worker

County

NAME – Community Waiver Participant

Case / ID Number

Social Security Number (Optional)

Reason for Termination

No longer meets functional/level of care eligibility

No longer resides in eligible living arrangement

Failed to meet post-eligibility requirements (ISP not signed, cost share payment(s) not made, spenddown not met, etc.)

Participant has notified the agency of his/her decision to discontinue program participation

Other—Specify: ________________________________________________________________________________

Additional Comments

Date Sent to IMW

SIGNATURE – CM/S&SC

Date Received by IMW

SIGNATURE - IMW

When a waiver participant moves to an ineligible living arrangement, the action of termination of waiver services may be

initiated without advance notice (42 CFR 431.213 (c)). This means that the LTSA notice can give an effective termination

date shorter than the normally required 10 days. Note that care managers still need to notify the ESA that waiver services are

being terminated.

Wisconsin Hemophilia Home Care Program Application