Form Dp 457 – Fill Out and Use This PDF

This application is from the Department of Public Welfare, Office of Developmental

Programs. If you need language assistance, free of charge, please call 1-888-565-9435.

HOME AND COMMUNITY-BASED ORICF/MR APPLICATION

AND SERVICE DELIVERYPREFERENCE FORM

I.CONFIRMATION OF UNDERSTANDING

I, ___________________________________________________________________ , have been informed of the following:

(NAME OF INDIVIDUAL)

a.That I am likely to require the level of care provided in an Intermediate Care Facility for people with Mental Retardation (ICF/MR). I understand that this is based on a preliminary determination of eligibility for

ICF/MR level of care, and that the determination will be subject to formal review.

b.About feasible home and community-based service alternatives to services provided in an ICF/MR

c.About my right to indicate a preference for home and community-based services funded under the Waiver as an alternative to services provided in an ICF/MR and about my rights to a fair hearing before the Department of Public Welfare, Bureau of Hearings and Appeals.

In declaring my preference for home and community-based services funded under the Waiver or ICF/MR,

I, ___________________________________________________________________ , understand the following:

(NAME OF INDIVIDUAL)

a.That I must meet Department of Public Welfare eligibility standards to receive services funded by the Waiver or ICF/MR.

b.That a fair hearing and appeal will not be granted if I am appealing changes caused solely by state or federal law or regulation requiring a change in the type of services available.

c.That completion of Service Delivery Preference does not guarantee services. Availability of State and Federal funds control the allocated resources for individuals to be served in the Waiver.

II.DESIGNATION OF SERVICE PREFERENCE

My service preference is: (initials or mark of individual, surrogate, or QMRPbeside one option)

Home and community-based services funded under the Waiver

Services in an ICF/MR

None at this time (If this option is chosen, Section III. does not apply.)

III.APPLICATION

Please indicate agreement and understanding of the following: (initials or mark of individual, surrogate, or QMRP beside each option)

I, ____________________________________________________ , hereby make application to be considered for the

(NAME OF INDIVIDUAL)

above indicated services for individuals with mental retardation.

I, ____________________________________________________ , understand that by submission of this application,

(NAME OF INDIVIDUAL)

I can expect a formal assessment of my need for services by the County/Administrative Entity.

DP457 01/08

IV. PARTICIPANT INFORMATION AND SIGNATURES

A.Individual. (This section must be completed for the individual who is requesting services).

INDIVIDUALNAME:

ACCESS NUMBER:

CURRENTSTREETADDRESS:

CITY:	STATE:	ZIP:		TELEPHONE NUMBER:
				(	)
SIGNATURE:			DATE:

B.Surrogate. (This section must be completed when the individual’s surrogate signifies the preference for Waiver or ICF/MR services on the individual’s behalf.)

NAME:

STREETADDRESS:

CITY:	STATE:	ZIP:		TELEPHONE NUMBER:
				(	)
SIGNATURE:			DATE:

C.Independent Qualified Mental Retardation Professional. (This section must be completed by the independent qualified mental retardation professional who is responsible to document the individual’s preference for Waiver or ICF/MR services).

NAME:

AGENCY:

STREETADDRESS:

CITY:	STATE:	ZIP:		TELEPHONE NUMBER:
				(	)
SIGNATURE:			DATE:

D.County MH/MR Program/Administrative Entity Designee. (This section must be completed by the County MH/MR Program/Administrative Entity that offers the individual or surrogate the preference for Waiver or ICF/MR services).

COUNTYDESIGNEE NAME:

TITLE:

AGENCYSTREETADDRESS:

CITY:	STATE:	ZIP:		TELEPHONE NUMBER:
				(	)
SIGNATURE:			DATE:

DP457 01/08