Participant Name: Address: CSP: CM Provider/CM: CM Email: Date participant requested discharge (provide the date the CM or CSP was informed by the participant/guardian of discharge): Date of Discharge (provide the anticipated date the participant is leaving services): Type of discharge: Participant is leaving CSP services only Participant is leaving all HCBS services Participant is changing CM provider (an SCR needs to be submitted identifying new CM provider along with DHS-DD-750) Participant is changing CSP (an SCR need to be submitted outlining all services at new CSP along with DHS-DD-750) Date SCR was initiated for provider changes if applicable: Reason participant is requesting discharge: Brief history of services prior to enrollment: Summary of significant events during the period of service to the participant (What worked well, what should stay the same, what didn’t work well, and what would you change): Date the CSP/CM provided participant and or guardian (include name of guardian, if applicable) information regarding other services and providers available to the participant: Summary of conversation or supporting documentation on how information was provided on alternative services in an accessible format to the participant/guardian: Provider’s request for further assistance from the Division of Developmental Disabilities:
Participant Name: Address: CSP: CM Provider/CM: CM Email: Date participant requested discharge (provide the date the CM or CSP was informed by the participant/guardian of discharge): Date of Discharge (provide the anticipated date the participant is leaving services): Type of discharge: Participant is leaving CSP services only Participant is leaving all HCBS services Participant is changing CM provider (an SCR needs to be submitted identifying new CM provider along with DHS-DD-750) Participant is changing CSP (an SCR need to be submitted outlining all services at new CSP along with DHS-DD-750) Date SCR was initiated for provider changes if applicable: Reason participant is requesting discharge: Brief history of services prior to enrollment: Summary of significant events during the period of service to the participant (What worked well, what should stay the same, what didn’t work well, and what would you change): Date the CSP/CM provided participant and or guardian (include name of guardian, if applicable) information regarding other services and providers available to the participant: Summary of conversation or supporting documentation on how information was provided on alternative services in an accessible format to the participant/guardian: Provider’s request for further assistance from the Division of Developmental Disabilities:
751%20Discharge.docx