Waiver ICF/ID LOC documentation – Initial (no waiver capacity)
DATE
Individual’s or Surrogate’s Name
Address
Address
Dear [Name of Individual or Surrogate]:
You are receiving this letter because you expressed an interest in receiving Waiver services through the Office of Developmental Programs. You were determined “likely to meet” intermediate care facility for individuals with intellectual disability (ICF/ID) Level of Care and indicated under Service Preference – Waiver services. This letter is to inform you that waiver capacity is not available at this time. It is our intent to proceed with enrollment when capacity becomes available.
While capacity is not available at this time, you are eligible to receive Supports Coordination services through TargetedSupports Management (TSM). The Administrative Entity (AE) will provide you with additional information and your choice of a Supports Coordination Organization (SCO).
If you have any questions regarding this letter, please contact me at __(Telephone Number)___.
Sincerely,
Name
Waiver Coordinator
County MH/ID Program or Administrative Entity
Enclosure
MA 51, Medical Evaluation
cc: Individual’s File
Individual’s Surrogate [if applicable]
Supports Coordinator
Waiver ICF/ORC LOC for children prior to age 9 with Developmental Disabilities documentation – Initial (no waiver capacity)
DATE
Individual’s or Surrogate’s Name
Address
Address
Dear [Name of Individual or Surrogate]:
You are receiving this letter because you expressed an interest in receiving Waiver services through the Office of Developmental Programs. You were determined “likely to meet” intermediate care facility for persons with other related conditions (ICF/ORC) Level of Care for children prior to age 9 with Developmental Disabilities and indicated under Service Preference – Waiver services. This letter is to inform you that waiver capacity is not available at this time. It is our intent to proceed with enrollment when capacity becomes available.
If you have any questions regarding this letter, please contact me at __(Telephone Number)___.
Sincerely,
Name
Waiver Coordinator
County MH/ID Program or Administrative Entity
Enclosure
MA 51, Medical Evaluation
cc: Individual’s File
Individual’s Surrogate [if applicable]
Supports Coordinator
Waiver ICF/ORC LOC for people with ASD documentation – Initial (no waiver capacity)
DATE
Individual’s or Surrogate’s Name
Address
Address
Dear [Name of Individual or Surrogate]:
You are receiving this letter because you expressed an interest in receiving Waiver services through the Office of Developmental Programs. You were determined “likely to meet” intermediate care facility for persons with other related conditions (ICF/ORC) Level of Care for people with Autism Spectrum Disorder (ASD) and indicated under Service Preference – Waiver services. This letter is to inform you that waiver capacity is not available at this time. It is our intent to proceed with enrollment when capacity becomes available.
While capacity is not available at this time, you are eligible to receive Supports Coordination services through TargetedSupports Management (TSM). The Administrative Entity (AE) will provide you with additional information and your choice of a Supports Coordination Organization (SCO).
If you have any questions regarding this letter, please contact me at __(Telephone Number)___.
Sincerely,
Name
Waiver Coordinator
County MH/ID Program or Administrative Entity
Enclosure
MA 51, Medical Evaluation
cc: Individual’s File
Individual’s Surrogate [if applicable]
Supports Coordinator