Provider Forms

Informational Notices from DODD

The Ohio Department of DD will be sending a series of informational notices related to compliance with Medicaid Home- and Community-Based Services requirements.

1. Service Documentation Requirements dated 6/11/2013
   

Service Delivery Documentation Forms

• HPC - Monthly 
• HPC Split Shift - Monthly 
• HPC and On-Site On-Call (OSOC) - Monthly 
• HPC - Two-Week 
• Adult Foster Care - Monthly 
• Adult Family Living - Units 
• Adult Family Living - Daily Rate 
• HPC Service Delivery Sample
• Non-Waiver Service Delivery Form 

Skill Development Documentation Forms

• Skill Development - Monthly 
• Skill Development - Two Week 
• Sample Skill Development Documentation 

Transportation Documentation Forms

• HPC Transportation Documentation Sheet
  • Sample Transportation HPC Documentation
• Non-Medical Transportation Documentation Sheet
  • Sample Non-Medical Transportation Documentation

Money Management Documentation Forms

• Individual Funds Transaction Record
• Individual Gift Card Transaction Record
• Individual Inventory Record
• Cost to Live Subsidy Guidelines 
• Sample Individual Funds Transaction Record
• Sample Individual Gift Card Transaction Record
• Cost to Live Subsidy Application
• Sample Provider Compliance Review
  • Agency Providers
  • Individual Providers

Medication Administration Record (MAR)

• Medication Administration Record (MAR)

Unusual Incidents

• Unusual Incident Form 
• Unusual Incidents Log Form

Plan Revision Request

• Plan Revision Request Form
• What Is a Revision Request?

Agency Provider Forms

Adult Day Support

• Adult Day Support/Vocational Habilitation Goal Sheet
• Adult Day Support/Vocational Service Documentation 
• Adult Day Service Summary 

BCI-Only (Use one of these forms.)

• Criminal Notification Form - Single Page 
• Criminal Notification Form - Tier 
• 2013 BCI Rule 

Request for Additional Nursing Hours

• Request for Additional Nursing Hours