DEPARTMENT OF HEALTH SERVICES STATE OF WISCONSIN Division of Medicaid Services Wisconsin Statutes F-00926 (02/2017) § 51.61(1)(i) Administrative Code DHS 94.10 REQUEST FOR USE OF RESTRAINTS, ISOLATION, OR PROTECTIVE EQUIPMENT AS PART OF A BEHAVIOR SUPPORT PLAN - CLTSS Although completion of this form is voluntary, all the information requested on this form needs to be submitted as part of the approval process. Personally Identifiable Information is collected on this form for the sole purpose of identifying the waiver participant and processing the request, and will not be used for any other purpose. Name - Consumer Birth Date Type of Request New Review Current Address - Consumer City State Zip Code all that apply): CLTSS-DD CLTSS-PD CLTSS-SED Individual’s Applicable Target Group(s) (check Name Parent/Guardian Telephone Number - Parent/Guardian – Current Residence - Consumer Personal/Family Residence (Same address as above) Licensed or Certified Facility, (Provide name and address below.) e.g., Foster Home, Adult Family Home, Shift Staff Treatment Foster Home Other (Describe and provide address below.) Residence Street Address (if different from above) City State Zip Code 1) Name Waiver Provider/ Agency that will use the restrictive measure – Waiver Service Type and Frequency Address- Waiver Provider/Agency Telephone Number City Fax Number State Zip Code Email Address 2) Name Waiver Provider/ Agency that will use the restrictive measure – Waiver Service Type and Frequency Address- Waiver Provider/Agency Telephone Number City Fax Number State Zip Code Email Address County Waiver Agency Submitting This Request Date Submitted Contact Person/Support & Service Coord. Telephone Number Fax Number Email Address Address Agency City – State Zip Code Definitions or the following apply. Check “Yes” “No,” if
DEPARTMENT OF HEALTH SERVICES Division of Medicaid Services F-00926 (02/2017) STATE OF WISCONSIN Wisconsin Statutes § 51.61(1)(i) Administrative Code DHS 94.10 REQUEST FOR USE OF RESTRAINTS, ISOLATION, OR PROTECTIVE EQUIPMENT AS PART OF A BEHAVIOR SUPPORT PLAN - CLTSS Although completion of this form is voluntary, all the information requested on this form needs to be submitted as part of the approval process. Personally Identifiable Information is collected on this form for the sole purpose of identifying the waiver participant and processing the request, and will not be used for any other purpose. Name - Consumer Birth Date Type of Request New Review Current Address - Consumer City State Zip Code Individual’s Applicable Target Group(s) (check all that apply): CLTSS-DD CLTSS-PD CLTSS-SED Name – Parent/Guardian Telephone Number - Parent/Guardian Current Residence - Consumer Personal/Family Residence (Same address as above) Licensed or Certified Facility, e.g., Foster Home, Adult Family Home, Shift Staff Treatment Foster Home (Provide name and address below.) Other (Describe and provide address below.) Residence Street Address (if different from above) City State Zip Code 1) Name – Waiver Provider/ Agency that will use the restrictive measure Waiver Service Type and Frequency Address- Waiver Provider/Agency Telephone Number City State Zip Code Fax Number Email Address 2) Name – Waiver Provider/ Agency that will use the restrictive measure Waiver Service Type and Frequency Address- Waiver Provider/Agency Telephone Number City State Zip Code Fax Number Email Address County Waiver Agency Submitting This Request Date Submitted Contact Person/Support & Service Coord. Telephone Number Fax Number Email Address Address – Agency City State Zip Code Definitions Check “Yes” or “No,” if the following apply.
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