Forms and Publications Related to the Children's Long-Term Support Waivers

• Regional Children's Services Specialists Contact Information (PDF, 22 KB)

Materials Specific to Autism Related Services Through the Waivers

• SPC 512 of the Medicaid Waivers Manual contains specific information regarding allowable services and requirements that must be met while participating in Intensive In-Home Treatment Services.

• Rights and Responsibilities of Families Participating in Intensive In-Home Treatment Services (PDF, 19 KB)

• "Roadmap" to Intensive Services (PDF, 27 KB)

• Autism Diagnosis Confirmation (PDF, 17 KB)

• Procedure for Accessing Medicaid Eligibility for Children on the State Wait List for Intensive In-Home Treatment Services (PDF, 17 KB)

• Information Regarding Medicaid Fee-For-Service Card Services (PDF, 26 KB)

• Redetermination of Eligibility Process for Children Waiting for Waiver Slot for Intensive In-Home Treatment Services (PDF, 20 KB)

• Transition to Ongoing Services Policy (PDF, 15 KB)

Materials Related to All Services Through the Waivers

• Citizenship Verification Memo (PDF, 16 KB)

• Critical Incident Reporting Overview (PDF, 24 KB)

• Critical Incident Report (Form DDE-2541)

• CLTS Local Match Eligibility Chart (PDF, 16 KB)

• Parental Payment Limits (formerly "Parental Fee")

• CLTS School Policy (PDF, 19 KB)

• CLTS State Match Eligibility Chart (PDF, 18 KB)

• CLTS Waiver Termination Policy (PDF, 93 KB)

• CLTS Waiver Translation Policy (PDF, 13 KB)

• Policy for Transferring a Child from the CIP Waiver to the CLTS Waiver (PDF, 12 KB)

• Policy for Transferring a Child from the CLTS Waiver to the CIP Waiver (PDF, 11 KB)

• Missed Services Policy (PDF, 16 KB)

• Determination of Exceptional Care Needs for Children in Child Care or Foster Care Setting (Form DDE-1072) (PDF, 22 KB)

• Informed Consent - Children's Long-Term Support Functional Screen (Form DDE-1076) (Word, 44 KB)

• CLTS Functional Screen: Change in Eligibility (PDF, 17 KB)

Checklists and Letters for Use by County Waiver Agencies

• Child Information Eligibility Worksheet (Word, 301 KB)
• Intensive In-Home Treatment Services Criteria Checklist (Form DDE-1077) (Word, 66 KB)

• CLTS One-Time Funding Request (Form DDE-1161) (Word, 41 KB)

• CLTS One-Time Funding Request (Form DDE-1161) (PDF, 14 KB)

• CLTS Waivers Application Checklist (Form F-21080) (Word, 87 KB)
• CLTS Waivers Recertification Checklist (Form F-21078) (Word, 75 KB)
• Sample Health Savings Account Letter (Word, 26 KB)
• Sample Level of Care Initial Denial Letter (Word, 37 KB)
• Sample Level of Care Termination Letter (Word, 37 KB)
• Sample Policy-Related Termination Letter (Word, 31 KB)

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Last Revised: August 22, 2008