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ADW Policy and Forms

​​​​​​​​​​​​​​​​​​​​​​​​​​Click here to view Chapter 501, the Aged and Disabled Waiver Policy.
Archived Forms

PDF ​Version Forms Instructions/Comments

Word/Excel Version Forms​
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Do Not Alter Forms

Additional Informal Supports​
Additional Informal Supports
​Additional Physician Information
Additional Physician Information
ADW Assessment Chart

AD​W Notes
ADW Notes Instructions 
​ADW Notes
ADW Procedural Guidelines for Closure of Unsafe and Noncompliance 
This is a guidance document and is not a policy

Case Management Person-Centered Assessment
​Case Management Per​son-Centered Assessment Instructions 
Case Management Person-Centered Assessment
Case Management Initial Contact ​Log
Case Management Initial Contact Log Instructions
Case Management Initial Contact Log
Case Management Monthly-Quarterly Contact
​Case Management Monthly-Q​uarterly Contact Instructions
Case Management Monthly-Quarterly Contact
Case Manager Conflict of Interest Assurance Form
​​​Case Manager Conflict of Interest Assura​nce Form
Conflict-Free Case Ma​nagement Director Attestation
​Conflict-Free Case Management Director Attestation
ADW Conflict of Interest Exception Application​​
ADW Conflict of Interest Exception​​ Application Instructions​

Extreme Situation Guide
​Required initial safety training for all personal attendant staff.
​FOB Order Form
​FOB Order Form
​Interim Service Plan
Interim Service Plan Instructions
​Interim Service Plan
Medication Profile
Medication Profile Instructions
​Medication Profile​
Medical Necessity Evaluation Request (MNER) Form
Medical Necessity Evaluation Request (MNER) Instructions Medical Neces​sity Evaluation Request (MNER) Form
Member-Controlle​d Setting​ Assessment

​Notification of Death Form

Notification of Death Instructions ​
Notification of Death Form
ADW Member Grievance
ADW Member Grievance Instructions
ADW Member Grievance
Personal Options Assessment

Personal Optio​ns Assessment​
​Personal Attendant Log (PAL) Full-Month Landscaped

​Personal Attendant Log (PAL) Full-Month Landscaped​​

​Personal Attendant Log (PAL)

​Person​al Attendant Log (PAL)
Responsibility Agreement Adapted Version
Responsibility Agreement Examples ​​Responsibility Agreement Examples
Responsibility Agreement Template Responsibility Agreement Template
​Request for Discontinuation of Service
Request for Discontinuation of Service
RN Person-Centered Assessment
RN Person-Centered Assessment Instructions
RN Person-Centered Asses​sment
​RN Contact
RN Contact Instructions 
​RN Contact
​Self-Audit/Self-Report Form
Standard Re​payment Form
Payment Voucher
Resource Consultant Contact Form
Request for Service Level Increase 
Request for Service Level Increase Instructions
Request for Service Level Increase
​Service Plan
Service Plan Instructions
Serv​i​ce Plan
​Service Plan Additional Page
S​ervice Plan Additional Page
Service Plan Add​​endum
Service Plan Addendum Instructions
Service Plan Addendum
ADW Annual Personal Attenda​nt Training Verification 

ADW Annual Personal Attend​ant Training Verification
​ADW Initial Personal Attendant Training Verification 
ADW Initial Personal Attendant Training Verification
​ADW Initial and Annual Case Management Training Verification 

ADW Initial and Annual Case Management Training Verification​​​​
​ADW Initial and Annual RN Training Verification 

​ADW​ Initial and Ann​ual RN Training Verification
​Transfer Notification Form

Transfer Notification Form
ADW Recipient User Guide

The User Guide is initially distributed to ADW members by the case manager. 

ADW Request for Environmental Accessibility Adaption (EAA)
ADW Request for EAA Instructions
ADW Request to Transfer
ADW Request to Transfer Instructions​
​​ADW Request to Transfer
WV Statewide Transition Plan Bro​chure