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Case Management Forms

 Back to the Community Programs Page



Comprehensive and Supports Waiver Forms 


NEW - Case Manager Training Handouts from November 2015 - posted 12-16-2015



Rights Restrictions 101

·  NEW - Rights Restriction Process Flow Chart - posted 1/22/2016

·  NEW - What are Rights Restrictions? - posted 1/22/2016

·  NEW - What Does CMS Say About Rights Restrictions? - posted1/22/2016

Case Management Plan, Monitoring, and Billing Forms

·   Home Visit and Service Observation Signature Form Revised 2-01-2016 in PDFWord 

·  Case Management Guidance for Billing and Documentation Posted 12-09-2014

·   Community Integration Schedule Form Posted 10-27-2014

·   Case Management 15 Minute Unit Tracking Form Posted 10-21-2014

·   Case Management 15 Minute Unit Tracking Form Sample Posted 10-21-2014

·    Third Party Liability Form Docx Posted 4-23-2015

·    Third Party Liability Form PDF Posted 4-23-2015

·   Behavioral Support Service Sample Form Posted 4-2-2014

·   Behavioral Support Service Fillable Form Posted 4-2-2014

·   Crisis Intervention Service Request Form Posted 4-2-2014

·   Transportation Mileage Log Posted 4-2-2014

·  Case Management Selection Form Revised 2-1-2016

·   Case Management Monthly Review Form (effective 7-1-2012)
Case Management Quarterly - Effective September 2012, this form submitted electronically in Electronic Medicaid Waiver System (EMWS)

IPC Forms

·   Habilitation Support (effective August 2012)
·   ICAP Authorization (effective September 2012)
·   Revised Team Signature and Verification Form DOC (Revised 2-2016) PDF Form
·   Verification Form - used in EMWS last step for submitting IPC

·   Plan of Care Worksheet for EMWS Rev. 3-2016

         - example completed Child IPC
- example completed Adult IPC

·  Planning Workbook for IPC

·  "About Me" worksheet (Revised September 2012)

·  File Naming Convention -  used in EMWS for uploading files (Revised 2-24-2016)

 Functional Assessment - sample
(Template is sample that can be used to explore the reasons behaviors are occurring and can be used to develop Positive Behavior Support Plan.)

·  Medication Assistance Record

·  Medication Consent Form

·  "My Medical Services" worksheet

·  Participant Specific Training form

·  Positive Behavior Support Plan- sample
(Template is sample to guide in building a Positive Behavior Support Plan. Other versions are acceptable provided the components of the IPC align with Chapter 45 of Wyo Medicaid Rules.)

·  Request Goods & Services through Self-Direction: Step by Step Instructions

·  Rights, Responsibilities, and Restrictions Guide
(Case Managers can use this tool to review the Participant and guardian's rights and responsibilities at least every six months or more as needed.)

·  Rights, Responsibilities, and Restrictions Worksheet

·  Supervision Level and/or Intervention Request
(Use this form if requesting a higher or lower support tier in Residential or Day Habilitation or requesting intervention units)

·  Waiver Application & Eligibility Guide - for Adult and Child DD Waivers

IPC Documents and Related Materials

·  Link to current Service Definitions and Fee schedules

· Individualized Plan of Care Documents (for Adult DD, Child DD, ABI)

· Non-Compliance Form

· Out-of-Home Placement Request PDF

· Out-of-Home Placement Request Word Doc

· Psychological Requirements

· Support Broker Opt Out Request Formwith Case Manager assessment (posted 3-18-2011)

· Support Broker Opt Out Process Flow

· Relative Disclosure Form

Note on opt out form:
Participant may request to opt out of receiving Support Brokerage services after the first year of self-directing at least one direct care service based on demonstrated competency in hiring, firing, training, supervising, scheduling workers, and reviewing timesheets in a timely manner.

The request to opt out shall be reviewed by the Participant’s Case Manager, who shall make an assessment of the Participant’s competency to self-direct successfully without a support broker.

The request and assessment shall be submitted to the Developmental Disabilities Section for approval. Instructions are on the form.  

Supplemental Service FormsFor services included on a Participant's IPC, a supplemental form is completed by the provider and sent to the Case Manager before the IPC is submitted to the Division. Objectives are required for habilitation services, but do not need to be sent to the Division with the IPC.

·   Checklist for requesting Specialized Equipment

·   Environmental Modifications

·   Goods & Services (Available if Self-Directing through PPL)

·   Skilled Nursing -physician's order form posted 7-23-2013

·   Specialized Equipment

·   Unpaid Caregiver Training (Available if Self-Directing through PPL)


 Sample Objectives and Schedules

These are only samples and are not required to be used. Providers may develop their own schedules with input from the participant and team, which align with the documentation requirements listed in Chapter 45 of the Wyoming Medicaid Rules.

·   Example of Completed Objective & Schedule

·   Employment Objectives

·   Habilitation Objectives (For Supported Living, Res & Day Hab, Special Family Hab Home, Child Hab Srvs)

·   Personal Care Schedule - or PDF

·   Residential Habilitation Training Schedule

·   Respite Schedule - or PDF

·   Special Family Hab Home Schedule - or PDF

·   Sample Day Habilitation Schedule (With behavior plan and objective data collection components)

·   Sample Intervention Hours Schedule

·   Sample Residential Habilitation Schedule

·   Sample Task Analysis Sheet   

Case Management FAQ's

Case Management vs. Support Brokerage Responsibilities

 ECC and IBA Adjustment Forms

Transition Forms


Electronic Medicaid Waiver System (EMWS)

Employment Planning

 Clinical Review Team Materials

 For Level of Service Need Scoring Rubric, please reference the last page of the


 ABI Waiver

         ·   ABI Waiver Neurological Requirements

 Supervision Flexibility Form

         ·   Supervision Flexibility Form Posted 2-27-14

Note: Providers who are implementing staffing flexibility must discuss the changes in staffing with the participant or guardian and case manager. This form must be signed by all parties and uploaded to EMWS in the person's document library by June 1, 2014.

 Targeted Case Management


Team Meetings