CLTS Waiver (Indicate Target Group): DD MH PD Jodi Williams CCS CIP 1A CIP 1B BIW CIP II COP-W COR CCOP Rebecca Hardell CLTS 3. Name - Applicant/Participant 4. Medicaid ID Number 5. Outcome Number 6. Desired Outcome(s) Addressed in Service Plan 7. Outcome Status or Progress Update 8. Date 1 2 3 4 5 6 7 8 63 64 65 65a 65b 66 67 68 69 Outcome Service Provider Name Address and Start Date End Date Unit Cost Authorized Units of Service Daily Cost Funding Source 62 Service Name* No. Telephone No. ($/hr; day) and Frequency (total yearly ÷ Service (#/day or (F-20445A (Email, cell phone no., if known) week or month) 365 days) Code # #5) SPC Jodi Williams, MCCS 510.10 480 Underwood Ave., Montello, CCS Service 1 WI $91.41/hr 4 hours/month $12.02 Facilitation 608-297-3132 MA Rebecca Hardell, MCDHS 428 Underwood Ave., Montello, SPC WI 604 Support and 608-297-3116 Service Coordinator 1,2, 3 1/31/18 12/31/18 $84.24/hr 2.5 $6.92 CLTS Waiver
CLTS Waiver (Indicate Target Group): DD MH PD CIP 1A CIP 1B BIW CIP II COP-W COR CCOP Jodi Williams CCS Rebecca Hardell CLTS 3. Name - Applicant/Participant 4. Medicaid ID Number 5. Outcome Number 6. Desired Outcome(s) Addressed in Service Plan 7. Outcome Status or Progress Update 8. Date 1 2 3 4 5 6 7 8 62 Service Code # 63 Service Name* 64 Outcome No. (F-20445A #5) 65 Service Provider Name Address and Telephone No. (Email, cell phone no., if known) 65a Start Date 65b End Date 66 Unit Cost ($/hr; day) 67 Authorized Units of Service and Frequency (#/day or week or month) 68 Daily Cost (total yearly ÷ 365 days) 69 Funding Source SPC 510.10 SPC 604 CCS Service Facilitation Support and Service Coordinator 1 1,2, 3 Jodi Williams, MCCS 480 Underwood Ave., Montello, WI 608-297-3132 Rebecca Hardell, MCDHS 428 Underwood Ave., Montello, WI 608-297-3116 1/31/18 12/31/18 $91.41/hr $84.24/hr 4 hours/month 2.5 $12.02 $6.92 MA CLTS Waiver