This explains who currently makes legal decisions for you. Do you take care of yourself? Does someone else take care of you? If someone else takes care of you, you will need that person’s name, address and telephone number.
You will need to provide all information for your health insurance provider(s) including policy and medical record numbers.
Forms and Evaluations
The DOH case manager will provide the forms your physician will have to complete and sign. The physician’s evaluation will help determine if you meet the DHS Intermediate Care Facility/Mental Retardation Level of Care (ICF/MR LOC). Refer to the Resources, Sample Forms section for a sample Physician’s Recommendation for ICF-MR LOC form.
Your DOH case manager will complete an eligibility (DHS 1150c) form and forward it to the DHS representative for review along with your application materials. The DHS representative will review your application materials and if you qualify, sign the DHS 1150c form to indicate DHS’ approval of your ICF/MR LOC.
Service Authorization Form
Your case manager will ask you to sign a Service Authorization Form (SAF). The SAF indicates your choice to receive home and community- based services instead of institutional services. This form is proof that you are choosing to participate in “The Waiver” of your own free will. Refer to the Resources, Sample Forms section for a sample SAF.
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