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Department of Health and Human Resources, Bureau for Medical Services Department of Health and Human Resources, Bureau for Medical Services
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Department of Health and Human Resources, Bureau for Medical Services Department of Health and Human Resources, Bureau for Medical Services
Home and Community-Based Services
Facebook Twitter
Apply Now for a Medicaid Waiver!

Policy and Forms

​​​​​​​Chapter 513 Intellectual and Developmental Disabilities Waiver Policy

Policy Clarifications
Clic​​k​ ​​h​​​​e​​r​​​e to view the newest Policy Clarifications

Approved IDDW Forms
Effective December 1, 2015

PDF Version​​​                   Information              

  Instructions​

 

 ​Microsoft Word Version
Please note the file may ask for a password
just press Enter.
​IDDW 2015 Manual Training Registration Form ​How to Report Abuse/Neglect Brochure ​ ​
​IDDW Case Management Only Agency Certification Application
​

​

​IDDW​ Case Management Only ​Agency Certification Application
IDDW 01 Application​

 ​ ​ ​IDD 01 Application​
​IDDW Atte​st​ation Form
​ ​ ​Not available in this format
​IDD Direct Support Services Living Arrangement Assessment
 ​ ​ ​​IDD Direct Support Services Living Arrangement Assessment
​​​IDD Direct Support Services Living Arrangement Assessment
(Short Form)
​
​​​IDD Direct Support Services Living Arrangement Assessment​
(Short Form)

IDD 02 Freedom of Choice​
 ​ ​ ​IDD 02 Free​d​om of Choice​
​IDD 03 SC HV_DV Combined
 ​
 ​ ​IDD 03 SC HV_DV Combined​
IDD 04 Initial Individualized Program Plan​
 ​ ​ ​IDD 04 Initial Individualized Program Plan​
​IDD 05 Individualized Program Plan (IPP)
 ​ ​ ​​IDD 05 Individualized Program Plan (IPP)
​IDD 06 Certificate of Training
 ​
 ​ ​IDD 06 Certificate of Training
​IDD 07 Direct Support Document
 ​ ​ ​​IDD 07 Direct Support Document
​IDD 08 Request for EAA G&S
 ​ ​ ​IDD 08 Request for EAA G&S
​IDD 09 Request for Nursing Services
 ​ ​ ​IDD 09 Request for Nursing Services
​IDD 10 Transfer Discharge
 ​ ​ ​IDD 10 Tra​nsfer Discharge
​IDD 11 Notification of Death Form
 ​ ​ Notification of Death Form ​​IDD 11 Notification of Death Form
​IDD 12 Request  to Continue Services
 ​ ​ ​IDD 12 Request to Continue Services
​IDD 13 Assessment Data Modification Request
 ​ ​ ​​IDD 13 Assessment Data Modification Request
​IDD 14 LPN Medication Admin Progress Notes
 ​ ​ ​IDD 14 LPN Medication Admin Progress Notes
​IDD 15 Remote Monitoring Application
​ ​ ​IDD 15 Remote Monitoring Application
​IDD 16 Remote Monitoring Eq​uipment
 ​ ​ ​IDD 16 Remote Monitoring
​IDD 17 Remote Monitoring Risk Assessment
​ ​ ​IDD 17 Remote Monitoring Risk Assessment
​Self-Audit/Self-Report Form ​ ​ ​
​Standard Repayment Form ​ ​ ​
​Payment Voucher ​ ​ ​

 ​IDD PC Dual Schedule Template Example ​
 ​

​Exception Request

 ​ ​

Excepti​on Request​
​​Exception Request Information and Che​cklist
​​​Exception Request Information and Checklist

​
Addendum to Current IPP
​​​
Addendum to Current IPP
​
Authorization Checklist
​

​

​​
Authorization Checklist
​
​COVID-19 Addendum
​​
COVID-19 Addendum​

 

Department of Health and Human Services, Bureau for Medical Services
Department of Health and Human Services, Bureau for Medical Services
Contact Us
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350 Capitol Street | Room 251 | Charleston, WV 25301 | Phone (304) 558-1700