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INDEX OF PDD WAIVER & STATE FUNDED PROGRAM FORMS

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CHAPTERS

 

 


 

 

 

 

 

Chapter 4

 

 

 

PDD Form 1-A    

Acknowledgement of Rights and Responsibilities - PDD Waiver

 

 

PDD Form 1-B    

Acknowledgement of Rights and Responsibilities - PDD State Funded Program 

 

 

PDD Form 2    

Freedom of Choice - PDD Waiver 

 

 

PDD Form 5    

Notice of Slot Allotment - PDD Waiver

 

 

PDD Form 9    

Request for ICF/ID Level of Care for the PDD Waiver

 

 

PDD Form 10    

Notice of Slot Allotment - PDD State Funded Program

 

 

PDD Form 30    

Request for PDD Slot Allocation Application

 

 

PDD Form 31-A  

Reconsideration /Appeals Process - PDD Waiver

 

PDD Form 31-B

Reconsideration/Appeals Process - PDD State Funded Program

 

PDD Form 42    

Consumer Insurance Verification 

 

 

PDD Form IR 1-A    

Information and Referral Application Packet-Process Explanation

 

 

PDD Form IR 1-B    

Information and Referral Application Packet-Records Request Letter

 

 

PDD Form IR 1-C   

Information and Referral Application Packet-Authorization for Release of Information

 

 

PDD Form IR 1-D  

Information and Referral Application Packet-

Acknowledgement of Case Management Choice

 

 

PDD Form IR  2  

Recommendation for Evaluation

 

 

PDD Form IR  3 

Notice of Denial of Services (Appeal Information Attached)

 

LOCS Form 1    

Level of Care Staffing Report

 

 

LOCD Form 2    

Level of Care Determination for ICF/ID

 

 

LOCC Letter    

Level of Care Certification Letter

 

 

Info-Sheet 1    

Pervasive Developmental Disorder Waiver Information Sheet

 

 

Info-Sheet 2    

Pervasive Developmental Disorder Program Fact Sheet

 

 

Info-Sheet 8    

Responsible Party Directed Care Enrollment Information

 

 

 

 

 

 

Chapter 5

 

 

 

PDD Form 11    

Authorization for Case Management Services - PDD Waiver

 

 

PDD Form 12    

Authorization for EIBI Services - PDD Waiver

 

 

PDD Form 13    

Authorization for EIBI Services- PDD State Funded Program

 

 

PDD Form 16-A  

Notice of Termination of Service - PDD Waiver

 

 

PDD Form 16-B  

Notice of Termination of Service - PDD State Funded Program

 

 

PDD Form 17-A  

Notice of Disenrollment - PDD Waiver

 

 

PDD Form 17-B  

Notice of Disenrollment - PDD State Funded Program

 

 

PDD Form 18    

PDD State Funded Program Billing Form

 

 

PDD Form 20-A  

Statement of Individual Declining PDD Waiver Services

 

 

PDD Form 20-B  

Statement of Individual Declining PDD State Funded Services

 

 

PDD Form 31-A  

Reconsideration /Appeals Process - PDD Waiver

 

 

PDD Form 31-B  

Reconsideration/Appeals Process - PDD State Funded Program

 

PDD Form 33

Authorization for Temporary EIBI Services - PDD State Funded Program

PDD Form 34

Notice of Disenrollment of Temporary Services - PDD State Funded Program

PDD Form 42 Consumer Insurance Verification
PDD Form 43 Pre Assessment Information
PDD Form 44 Temporary EIBI State Funded Program Enrollment Agreement

 

 

 

 

 

Chapter 9

 

 

 

PDD Form RP 1  

Pre-Screening Assessment of Responsible Party - PDD Program 

 

 

PDD Form RP 2  

Checklist of Items Needed for PDD Program Responsible Party-Direction of Services

 

 

PDD Form RP 5  

Responsible Party Information Sheet - PDD Program

 

 

PDD Form RP 8  

Line Therapist Information Sheet - PDD Program

 

 

PDD Form RP 9  

Electronic Funds Transfer and Payroll Tax Deduction Authorization

 

 

PDD Form RP 10  

Employee Payment Agreement - PDD Responsible Party Directed Services

 

 

PDD Form RP 11  

Line Therapist Responsibilities Agreement - PDD Program

 

 

PDD Form RP 12-A  

Line Therapy Services Liability Statement - PDD Waiver

 

PDD Form RP 12-B Line Therapy Services Liability Statement - PDD State Funded Program

 

PDD Form RP 15  

Line Therapist Qualifications Checklist - PDD Program

 

PDD Form RP 15-A PDD Tuberculin Skin Test Requirements

 

PDD Form RP 16  

Responsible Party Line Therapy Daily Log - PDD Program

 

 

PDD Form RP 17  

Authorization for Responsible Party Line Therapy -PDD Waiver

 

 

PDD Form RP 18  

Authorization for Responsible Party Line Therapy - PDD State Funded Program

 

 

PDD Form RP 19  

Responsible Party Line Therapist Invoice

 

 

Form SS-4    

Application for Employer Identification Number

 

 

Form 8821    

Tax Information Authorization

 

 

Form 2678    

Employer/Payer Appointment of Agent

 

 

Form I-9    

Employment Eligibility Verification

 

 

Form W-4    

Employee’s Withholding Allowance Certificate

 

Form DSS 3072

Consent to Release Information

 

Info-Sheet 8    

Responsible Party Directed Care Enrollment Information

 

 

 

 

 

 

Chapter 11

 

 

 

PDD Form 21    

EIBI Provider Application

 

 

PDD Form 22A-C    

EIBI Provider Enrollment Packet

 

 

PDD Form 40    

Consultant Recertification Application

 

 

PDD Form 41    

Consultant Annual Renewal Application