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HCBS Settings Modification Request

The HCBS Settings Final Rule ensures that all HOPE Waiver Medicaid participants who are residing in HCBS settings have control over their location, living arrangements, privacy, dignity and respect, physical accessibility, autonomy, and community integration.

In rare instances, certain rights may need to be restricted to ensure a participant's health and safety. Complete this form if a HOPE Waiver Medicaid participant in your setting requires a modification. The form will be reviewed by Long Term Services and Supports' (LTSS) HOPE Waiver Manager and, if appropriate, sent to the participant's Case Management Specialist to complete the modification process.

No Modification may begin until the Case Management Specialist has met with the HOPE Waiver Medicaid Participant and a signed copy of the Modification form is added to their Individual Support Plan.

Section 2 of 5 in this document

Facility Information

Name of Facility

Title

Email Address

Phone Number

Section 3 of 5 in this document

HOPE Waiver Participant Information

Medicaid Number

Section 4 of 5 in this document

Modification Information

Why is the modification being requested? Describe why this level of restriction is necessary and how the modification is consistent with the consumer's needs.

List of diagnoses and/or cognitive or physical impairments that limit the HOPE Waiver participant's ability to safely to complete the activity independently, if applicable.

Supporting documentation of diagnoses and/or cognitive or physical impairments.

What other less restrictive options were tried to help avoid this modification? (List all alternatives that were tried.)

Supporting documentation of less restrictive options that were tried.

How often will this restriction be reviewed by the facility to determine effectiveness and/or necessity? (Modifications cannot be implemented permanently; they must be reviewed regularly to determine necessity).

Without the implementation of the setting modification(s) requested, the health and safety of the HOPE Waiver Participant is at risk.

Yes

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HCBS Settings Modification Request

Facility Information

Address of Facility

Name of Person Filling out this Form

HOPE Waiver Participant Information

HOPE Waiver Participant Name

Modification Information

What type of Modification is being requested? (Check all that apply)

Supporting documentation of diagnoses and/or cognitive or physical impairments.

Supporting documentation of less restrictive options that were tried.

Without the implementation of the setting modification(s) requested, the health and safety of the HOPE Waiver Participant is at risk.

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