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Policy and Forms

​​​​​​​​​​​​​​​​​​​​​TBIW Services Manual
Chapter 512 Traumatic Brain Injur​y Waiver (TBIW) Policy Manual

TBIW Policy Clarifications/Updates

Approved TBI Waiver Forms

PDF Version Forms ​Form Instructions/Examples
Microsoft Word/Excel Form Versions
Please note the file may ask for a password
just press Enter.
Do Not Alter Forms
Monthly Case Management Log
Monthly Case Management Log
​​Case Manager Initial/Annual Training Log
​Case Manager Initial​Annual Training Log
Case Management Monthly Contact Form
​​Case Management Monthly Contact Form
​Conflict of Interest Exceptio​n Applicatio​n

​Environmental Accessibility Adaption (Home/Vehicle)
​​​Environmental A​ccessibility Adaption (Home/Vehicle)
​Enrollment Request Form
Good Day/Bad Day Discovery Tool
Good Day/Bad Day Discovery Tool Instructions
​Good Day/Bad Day Discovery Tool
​Grievance Form
​Grievance Form
​Interim Service Plan
​​Interim Service Plan
Medical Necessity Evaluation Request Form (MNER)
​Medica​l Necessity Evaluation Request Form (MNER)
​​Member-Controlled Settings Assessment
WV Statewide Transition​ Plan Brochure
​Living Arrangements and Setting Assessm​​ent Chart
​Member-Controlled Settings Assessment
Morning Rituals Discovery Tool
Morning Rituals​ Discovery Tool Instructions
Morning Rituals Discovery Tool
Notification of Death Form
Notification of Death Form Instructions ​Notification of Death Form
​​Person-Centered Service Plan Addendum

Person-Centered Service Plan Addendum
​Person-Centered Assessment
​Person-Centered Assessment
Person-Centered Assessment Additional Medication List
Person-Centered Assessment  Additional Medication List
Person-Centered Service Plan
​Person-Centered Service Plan
​​Personal Attendant Initial Annual Training Log
​Personal Attendant Initial Annual Training Log
​Personal Attendant W​orksheet
Personal Attendant Worksheet
Program Participa​​nt Budget Template
​​Provider Agency Change Request
Provider Agency Change Request
Request for Discontinuation of Service 
​Request for Discontinuation of Service 
​​Request for Internet-Based Training

​Request for Internet-Based Training
​Responsibility Agreement Template
​Responsibility Agreement Template
TBIW Prior Authorizati​on Cover Sheet
TBIW Prior Authorization Cover Sheet Instructions TBIW Prior Auth​orization Cover Sheet
​Transfer Request
​Transfer Request


 TBIW Information and Monitoring

Abuse R​eporting Brochure
Guidance S​ervice Plan and Quality Review
Home Visit Flyer
​Incident Management System Quick Tips October 2023
​​Self-Audit/Self-Report Form
​​Standard Repaym​ent Form
Payment Voucher
Provider Revie​w Tool​                                                                              TBIW Qu​ality Review Process
​​TBIW Change in Need G​uidance Document
TBIW Incident Management System Reporting Chart
Personal Attendant Assisting with Occupational Therapy and Physical Therapy 
​Tip Sheet Personal Attendant Services 2018
​Suggested Chart School-Aged TBIW Program 2018