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Forms and Documents

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Case Management Forms & Documents

Case Management Monthly Report    revised 6-21-2012 and effective 7-1-2012

Case Management Quarterly (Use for services given through June 30, 2012)

IBA Adjustment Request Form locked / unlocked form (posted 10-14-2010) Refer to 10-14-2010 IBA Adjustment and revised ECC policy and procedures Memorandum for details. 

ICAP Checklist

Targeted Case Management Forms

Provider Non-Compliance Form

Team Meeting Checklist in PDF

Out-of-Home Placement Request in PDF

Psychological Requirements in PDF

ABI Waiver Neurological Requirements in PDF

Plan of Care Documents

IPC Instructions  Revised April 2011!

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

Helpful IPC Tools

FY 2011 Waiver Service Rate Table without ratios listed, click here.

Request Goods & Services through Self-Direction: Step by Step Instructions in PDF format 

Rights, Responsibilities and Restrictions Tool (Case Managers shall review the participant and guardian's rights and responsibilities with this tool at least every six months or as needed)

Sample Positive Behavior Support Plan (This template is a sample that can be used to build a positive behavior support plan.  Other versions are available and acceptable to use as long as the components of the plan align with Chapter 45 of Wyo Medicaid Rules.)

Sample Functional Assessment (This template is a sample that can be used to evaluate a person's behaviors and what causes them, which is needed to build a positive behavior support plan).

Plan Review Form Instructions (This document shows the areas of compliance that the IPC shall address when reviewed by Division staff)

Supplemental Service Forms   

(For services included on a participant's IPC, a supplemental form shall be completed by the provider and sent to the case manager before the plan is submitted to the Division. Objectives are required for habilitation services but do not need to be sent to the Division with the plan of care). 


Supported Living 


Personal Care 


Cognitive Retraining 

Companion Services


Occupational Therapy 

Physical Therapy 

Speech Therapy 

Skilled Nursing (Physician's Order for Skilled Nursing)

Environmental Modifications 

Specialized Equipment          Checklist for requesting Specialized Equipment 


Subsequent Assessment 

Child Habilitation Service

Unpaid Caregiver Training (Available when self-directing through PPL)

Individually Directed Goods & Services (Available when 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.

Special Family Hab Home Schedule - Word or PDF

Respite Schedule - Word or PDF

Residential Habilitation Training Schedule - Word or PDF

Personal Care Schedule - Word or PDF

Homemaker Chart - Word or PDF 

Sample Day Habilitation Schedule --With behavior plan and objective data collection components

Sample Residential Habilitation Objective and Sample Task Analysis Sheet

Sample Residential Habilitation Schedule

Sample Intervention Hours Schedule