Policy and Forms

TBIW Services Manual
Chapter 512 Traumatic Brain Injury Waiver (TBIW) Policy Manual

TBIW Policy Clarifications/Updates

IMS Memo June 30. 2023
Home and Community-Based Services (HCBS) Rates Memo June 30, 2023
ADW/TBIW Provider Memo
TBIW Rate Increase Memo Effective April 2020

BMS Guidance on Legal Guardians/Medical Power of Attorneys
Guardianship Q&A Follow-Up
Approved POC Six-Month Follow Up
Disqualifying Findings added to WV CARES
BMS Reconsideration for Personal Attendants at Medical Appointments
CPS Reporting Memo

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 InitialAnnual Training Log
Case Management Monthly Contact Form		Case Management Monthly Contact Form
Conflict of Interest Exception Application
Environmental Accessibility Adaption (Home/Vehicle)		Environmental Accessibility Adaption (Home/Vehicle)
Enrollment Request Form		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)		Medical Necessity Evaluation Request Form (MNER)
Member-Controlled Settings Assessment WV Statewide Transition Plan Brochure	Living Arrangements and Setting Assessment 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 Worksheet		Personal Attendant Worksheet
		Program Participant 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 Authorization Cover Sheet	TBIW Prior Authorization Cover Sheet Instructions	TBIW Prior Authorization Cover Sheet
Transfer Request		Transfer Request

TBIW Information and Monitoring

Guidance Service Plan and Quality Review
Self-Audit/Self-Report Form
Standard Repayment Form
Payment Voucher
Provider Review Tool TBIW Quality Review Process
TBIW Change in Need Guidance Document
TBIW IMS Reporting Chart
Personal Attendant Assisting with Occupational Therapy and Physical Therapy (OT/PT)
Tip Sheet Personal Attendant Services 2018
Suggested Chart School-Aged TBIW Program 2018

Department of Health and Human Services, Bureau for Medical Services