Enhanced Supports Provider Request Templates Additional Residential Staffing and Extraordinary Staffing/Exceed Units

DBHDD Region: Provider: Individual Name:

Submission Date to Region:

Requested Start Date of Enhanced Supports (ARS or ES):

Requested End Date of Enhanced Supports (ARS or ES):

Service Requesting Exceptional Rates: (check all that apply)

Community Living Supports / Community Residential Alternative / Community Access Group
Specialized Medical Equipment / Specialized Medical Supplies

Enhanced Staffing/Exceed Units / Basis of Funding Request to Support as documented in the Clinical Review: (check all that apply)

Extraordinary Staffing Requirements: Enhanced paraprofessional, direct care staffing ratios either shared or one on one service delivery related to the direct care of the participant. Medical Behavioral Medical and Behavioral

CHECKLIST: PERTINENT RECORD DOCUMENTATION
Current service plan (Refer to CIS). / *Recent progress notes (case management, residential)
BSP, Behavior data tracking etc (Please upload in CIS Documents) / *Relevant legal documentation
Safety/Crisis Plan (Please upload in CIS Documents) / *Recent incident reports
*Medical support plan, Healthcare Plans/protocols / *Additional information: school records, IEPs, personal statement from past caregivers, proof of home modifications, doctor's notes, hospitalizations etc.

*Information is available to be reviewed in on-site records

Additional Residential Staffing Template –Specific Service Provision-Community Living Supports Budget Attached

Provider Name for CLS:
CLS Address:
Live with family/caretaker Live on own Shared Arrangement 2 person Shared Arrangement 3 person
A.  Staffing Summary: What prompted request? i.e.: change in condition or continuation due to extraordinary needs. Describe request need and all current services frequency/unit services the participant is receiving? Please explain here:
B.  Usage of hours within model and explain the usage of hours for each resident in the home: Please explain here and attach weekly staff schedules representing usage of hours for each resident within the home.
C.  How you are planning to use the additional hours? Please provide detail information as to when and how the additional hours will be utilized. Please explain here

Additional Residential Staffing Template –Specific Service Provision-Community Residential Alternative Supports Budget Attached

Provider Name for CRA
CRA Address:
Community Living Arrangement Personal Care Home Host Home
A.  Staffing Summary: What prompted request? i.e.: change in condition or continuation due to extraordinary needs. Please explain here: Describe request need and all current services frequency/unit services the participant is receiving? Please explain here:
B.  Usage of hours within model and explain the usage of hours for each resident in the home: Please explain here and attach weekly staff schedules representing usage of hours for each resident within the home.
C.  How you are planning to use the additional hours? Please provide detail information as to when and how the additional hours will be utilized. Please explain here:

Extraordinary Staffing Template –Specific Service Provision-Community Access Group

Budget Attached

Provider Name for CAG:
CAG Address:
Staffing Summary:

Exceeding Maximum Units –Specific Service Provision-Specialized Medical Supplies

SMS Itemized Budget Attached

Provider Name for SMS:
Justification: Please explain here

Exceeding Maximum Lifetime Units –Specific Service Provision-Specialized Medical Equipment

SME Itemized Budget Attached

Provider Name for SME:
Justification: Please explain here

Please review NOW/COMP Part II Appendix H and if applicable COMP Part III Additional Residential Staffing before sending the below request packet to your Regional Field Office to Request a Clinical Assessment upon updating HRST 120-90 days before requested start date for renewals and 30-45 days before requested start date of revision or initial request. (Incomplete packets are not accepted and will be returned). Prior approval must be provided before delivery of any enhanced service.

Initial/Renewal Provider ARS and ES Packet:

Enhanced Supports Request Template
Additional Residential Staffing or Extraordinary Staffing/Exceed Units Budget Request / Enhanced Supports Budget Additional Residential Staffing or Extraordinary Staffing/Exceed Units Budget Request / Crisis/Safety Plans
Behavioral Support Plan with required
signatures
Changes in Supports to Existing Enhanced Supports (Additional Residential Staffing or Extraordinary Staffing/Exceed Units Requests): Clinical Assessment must reflect need for changes
Enhanced Supports Request Template (Additional Residential Staffing or Extraordinary Staffing/Exceed Units)
Enhanced Supports Budget Template (Additional Residential Staffing or Extraordinary Staffing/Exceed Units)
Provider Contact Person:
Provider Contact Numbers: Office Cell / Title:
Field Office Contacts for Enhanced Staffing Requests Additional Residential Staffing (CRA/CLS), Extraordinary Staffing Requests (CAG) and Units Exceeding Maximum (SMS/SME)
Region / Position Title / Staff Name / E-mail
1 / Community Case Expeditor / Maxine Carelock /
2 / RQR Behavior Specialist / Michelle Broadwater /
3 / Community Case Expeditor / Rhonda Flint /
4 / Community Case Expeditor / Laurie Bradford /
5 / Community Case Expeditor / William “Tee” Scott /
6 / Community Case Expeditor / Pamela Byrd /

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