| Number |
Title |
| 6010 |
Transition to Life in the Community (TLC) - Application and Plan |
| 6500 |
Individual Plan of Care (IPC) - DBMD |
| 6500-T |
IPC Service Delivery Transfer Worksheet |
| 6502 |
Denial of Application for DBMD |
| 6503 |
DBMD Summary of Services Delivered |
| 6504 |
Prior Authorization for Dental Services |
| 6505 |
Daily Census Documentation |
| 6507 |
Rationale for Adaptive Aids, Medical Supplies, and Minor Home Modifications |
| 6508 |
Specifications for Minor Home Modifications |
| 6509 |
Request for Authorization of IPC Over Cost Ceiling |
| 6510 |
Decline of Offer for Deaf Blind with Multiple Disabilities (DBMD) Program Enrollment |
| 6511 |
Approval of Application for the Deaf Blind with Multiple Disabilities (DBMD) Program |
| 6600 |
Personal Support Preparation Worksheet |
| 6601 |
Legally Authorized Representative, Advocate, Correspondent Invitation Letter |
| 6601-S |
Legally Authorized Representative, Advocate, Correspondent Invitation Letter (Spanish) |
| 6602 |
Local Authority (LA) Invitation Letter |
| 6603 |
Personal Invitation Letter |
| 6603-S |
Personal Invitation Letter (Spanish) |
| 6604 |
Preplanning Questionnaire |
| 6604-S |
Preplanning Questionnaire (Spanish) |
| 6605 |
Personal Focus Worksheet |
| 6605-S |
Personal Focus Worksheet (Spanish) |
| 6606-A |
Risk Screening Tool - Constipation, Seizures, Specific Concerns |
| 6606-B |
Risk Screening Tool - Aspiration/Choking, Dehydration |
| 6606-C |
Risk Screening Tool - Behavior |
| 6609 |
Personal Support Plan |
| 6610 |
Achievements and Abilities |
| 6611 |
Assessments/Services the Person Uses/Needs |
| 6612 |
Risk Tracking Record |
| 6613 |
Agenda for Personal Support Plan (PSP) Meeting |
| 6614 |
Rights Assessment |
| 6614-A |
Consent/Authorization for Rights Restriction |
| 6614-AS |
Consent/Authorization for Rights Restriction (Spanish) |
| 6614-B |
Emergency Restrictive Practice |
| 6614-C |
Human Rights Committee Referral |
| 6614-D |
Human Rights Committee Review of Behavior Support Plan |
| 6614-S |
Rights Assessment (Spanish) |
| 6615 |
Admission Personal Support Plan (PSP) |
| 6619 |
General Discussion Record |
| 6620 |
Living Options Discussion Record |
| 6621 |
Program Integration Discussion Record |
| 6622 |
Action Plan |
| 6623 |
Personal Support Team Signature Sheet |
| 6624 |
Personal Support Plan Addendum |
| 6625 |
Personal Support Plan Addendum - Living Options |
| 6626 |
Personal Support Plan Addendum - Level of Supervision |
| 6627 |
Personal Support Plan Addendum - Psychoactive Medication Algorithm State Review of Behavioral Health and Environmental Interventions |
| 6628 |
Personal Support Plan Addendum - Four or More Restraints in a 30-Day Period |
| 6629 |
Personal Support Plan Addendum - Medical High Risk |
| 6630 |
Personal Support Plan Quarterly Report |
| 6631 |
Communications Dictionary |