Consumer Name: Date: Yes No EIS #: Receiving Waiver Services? DOB: If “Yes”, please specify: ………………………………………………………………………………………………………………………………………………………………… Case Manager (CM) Name: CM Agency: CM Address: CM Phone: CM Fax: CM Email: ………………………………………………………………………………………………………………………………………………………………… Describe items/services requested: Justification for request: Yes No Have all available funding options been explored? Describe options explored: Yes No Consumer (or family) able to contribute? If “No”, please describe budgetary constraints: Yes No CM verification funding need is documented in Person Centered Plan: ………………………………………………………………………………………………………………………………………………………………… Vendor Name: Vendor ID #: Vendor Address: Vendor Phone: Vendor Email: Vendor Fax: ………………………………………………………………………………………………………………………………………………………………… Yes No Billing Code:________________________ Approved? DHHS Signature:_____________________________ Date: ________________________
Consumer Name: Date: EIS #: Receiving Waiver Services? Yes No DOB: If “Yes”, please specify: ………………………………………………………………………………………………………………………………………………………………… Case Manager (CM) Name: CM Agency: CM Address: CM Phone: CM Fax: CM Email: ………………………………………………………………………………………………………………………………………………………………… Describe items/services requested: Justification for request: Have all available funding options been explored? Yes No Describe options explored: Consumer (or family) able to contribute? Yes No If “No”, please describe budgetary constraints: CM verification funding need is documented in Person Centered Plan: Yes No ………………………………………………………………………………………………………………………………………………………………… Vendor Name: Vendor ID #: Vendor Address: Vendor Phone: Vendor Email: Vendor Fax: ………………………………………………………………………………………………………………………………………………………………… Approved? Yes No Billing Code:________________________ DHHS Signature:_____________________________ Date: ________________________