DHHS Office of Aging and Disability Services Vendor Call Form Contact Name: Contact Phone: Contact Email: Fax Number: Contact Agency/ DHHS OADS Office: Unique Identifier: Age: Sex: Services Requested Services Section 20: Services Needed: Section 18: Needed: HCBS for Adults with Other Related Conditions HCBS for Adults with Brain Injury Assistive Technology Assistive Technology Care Coordination Care Coordination Career Planning Career Planning Community/Work Reintegration Community/Work Reintegration Employment Specialist Services Employment Specialist Services Home Support 1 (Quarter Hour) Home Support (Quarter Hour) – – Home Support Level II and Level III (Group Home) Home Support Per Diem Home) – – Home Support Remote Support Home Support Remote Support – – Self Care/Home Management Reintegration Self Care/Home Management Reintegration Work Ordered Day Club Work Ordered Day Club House Work Support Work Support PT OT SP PT/OT/Speech Maintenance Services Section 21: Services Section 29: Services HCBS Comprehensive Waiver Needed: HCBS Supports Waiver Needed: Assistive Technology Assistive Technology Career Planning Career Planning Community Supports Community Supports Consultation: Employment Specialist Services Employment Specialist Services Home Support - Quarter Hour Intermittent Home Support Agency Home/Per Diem Home Support - Remote Support – Home Support - Family Centered Support Home Support - Respite Home Support - Quarter Hour Intermittent Work Support Home Support - Remote Support Home Support Shared Living – PT/OT/Speech Maintenance Services PT OT SP PT/OT/Speech Maintenance Services Work Support Other Services: PNMI ICF/IID Geographic Preference Accessibility/Accomodations : (if needed) General service needs: Medical Behavioral Personal
DHHS Office of Aging and Disability Services Vendor Call Form Contact Name: Contact Phone: Contact Email: Fax Number: Contact Agency/ DHHS OADS Office: Unique Identifier: Age: Sex: Services Requested Section 18: HCBS for Adults with Brain Injury Services Needed: Section 20: HCBS for Adults with Other Related Conditions Services Needed: Assistive Technology Assistive Technology Care Coordination Care Coordination Career Planning Career Planning Community/Work Reintegration Community/Work Reintegration Employment Specialist Services Employment Specialist Services Home Support – 1 (Quarter Hour) Home Support – (Quarter Hour) Home Support – Level II and Level III (Group Home) Home Support – Per Diem Home) Home Support – Remote Support Home Support – Remote Support Self Care/Home Management Reintegration Self Care/Home Management Reintegration Work Ordered Day Club Work Ordered Day Club House Work Support Work Support PT/OT/Speech Maintenance Services PT OT SP Section 21: HCBS Comprehensive Waiver Services Needed: Section 29: HCBS Supports Waiver Services Needed: Assistive Technology Assistive Technology Career Planning Career Planning Community Supports Community Supports Consultation: Employment Specialist Services Employment Specialist Services Home Support - Quarter Hour Intermittent Home Support – Agency Home/Per Diem Home Support - Remote Support Home Support - Family Centered Support Home Support - Respite Home Support - Quarter Hour Intermittent Work Support Home Support - Remote Support Home Support – Shared Living PT/OT/Speech Maintenance Services PT/OT/Speech Maintenance Services PT OT SP Work Support Other Services: PNMI ICF/IID Geographic Preference Accessibility/Accomodations (if needed) : General service needs: Medical Behavioral Personal
VendorCallForm2016.docx