Individual’s Name Medicaid # Services being Requested OHCDS Provider Begin End Total Requested DDS Approved Procedure Code/ Check if Date Date Name and Number Applies Modifier/Service Units Amount Units Amount H2016 Supportive Living N/A N/A Respite Care N/A N/A S5165 U1 Adaptive Equipment N/A N/A S5160 Emergency Response N/A N/A System Installation and Testing S5161 Emergency Response N/A N/A System Service Fee S5162 Emergency Response N/A N/A System Purchase K0108 Environmental N/A N/A Modifications T2028 Specialized Medical N/A N/A Supplies T2020 UA Supplemental N/A N/A Support T2022 Care Coordination H2023 Supported Employment H2023 U1 SE Discovery U2 SE Job Development H2023 U3 SE Employment Path H2023 U4 SE Extended Support T2025 Consultation U1 UA Crisis Intervention T2022 U2 Transitional Care Coordination/PCSP development T2020 UA U1 Community N/A N/A Transition Services Total Provider Designee/Agency Signature Date DDS USE ONLY I have verified totals are within approved limits. I have compared this request to the prior year’s POC expenditures. If the request has a significant increase or decrease in the prior year’s POC expenditures, the provider has identified and justified in the PCSP Narrative why the amount increased/decreased from the prior year’s POC costs. Reviewed by Date Reviewed
Individual’s Name Medicaid # Provider Name and Number OHCDS Check if Applies Services being Requested Procedure Code/ Modifier/Service Total Requested Begin Date End Date DDS Approved Units Amount Units Amount H2016 Supportive Living N/A N/A Respite Care N/A N/A S5165 U1 Adaptive Equipment N/A N/A S5160 Emergency Response System Installation and Testing N/A N/A S5161 Emergency Response System Service Fee N/A N/A S5162 Emergency Response System Purchase N/A N/A K0108 Environmental Modifications N/A N/A T2028 Specialized Medical Supplies N/A N/A T2020 UA Supplemental Support N/A N/A T2022 Care Coordination H2023 Supported Employment H2023 U1 SE Discovery U2 SE Job Development H2023 U3 SE Employment Path H2023 U4 SE Extended Support T2025 Consultation U1 UA Crisis Intervention T2022 U2 Transitional Care Coordination/PCSP development T2020 UA U1 Community Transition Services N/A N/A Total Provider Designee/Agency Signature Date DDS USE ONLY I have verified totals are within approved limits. I have compared this request to the prior year’s POC expenditures. If the request has a significant increase or decrease in the prior year’s POC expenditures, the provider has identified and justified in the PCSP Narrative why the amount increased/decreased from the prior year’s POC costs. Reviewed by Date Reviewed
CES-703_Waiver_PCSP_Forms.docx